Quality Monitor Report 2011—Full Report

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Quality Monitor Report 2011—Full Report
QUALITYMONITOR
HEALTH QUALITY ONTARIO
2011 REPORT ON ONTARIO’S HEALTH SYSTEM
The quality of our health system is the responsibility
of every Ontarian. We hope this report will help you
understand the publicly funded health system better,
and give you the information you need to keep up
pressure for improvement.
After all, it’s your health and your health system.
This report is prepared in
partnership with
QUALITY MONITOR:
TABLE OF CONTENTS
1
INTRODUCTION AND SUMMARIES
2
6
1.1
Executive summary
2
6.1
Cost of service delivery
76
1.2
Quality improvement summary
6
6.2
Right service in the right place
78
1.3
Attributes framework
8
6.3
Avoidable emergency department visits
80
6.4
Avoiding unnecessary drugs and tests
82
Sector summaries
9
1.4
Hospital sector summary
1.5
Primary care summary
12
1.6
Home care summary
14
1.7
Long-term care summary
16
7
Disease summaries
2
3
4
5
1.8
Cardiovascular disease summary
18
1.9
Diabetes summary
19
1.10 Cancer summary
20
1.11 Mental health summary
21
1.12 Data advocacy
22
ACCESSIBLE
24
8
EFFICIENT
APPROPRIATELY RESOURCED
84
7.1
Overall spending and value for money
84
7.2
Information technology
86
7.3
Healthy work environments
90
7.4
Health human resources
92
INTEGRATED
8.1
9
76
Discharge/transitions from hospital and primary care
FOCUSED ON POPULATION HEALTH
94
94
98
98
9.1
Unhealthy behaviour
9.2
Maternal and infant health
102
2.1
Wait times in emergency departments
24
9.3
Sexual health
104
2.2
Access to primary care
28
9.4
Preventive measures
106
2.3
Treatment wait times and access to specialists
30
9.5
Deaths and harm that could be avoided by prevention 108
2.4
Access to long-term care and home care
36
EFFECTIVE
40
10 EQUITABLE
112
10.1 Primary care – access and effectiveness
112
3.1
Receiving the right treatments in hospital
40
10.2 Unhealthy behaviour
113
3.2
Chronic disease management
44
10.3 Preventive measures
114
3.3
Potentially avoidable hospitalizations
48
3.4
Keeping people healthy in long-term care
52
10.4 Diseases that could be avoided with
a population health focus
115
3.5
Keeping people healthy in home care
53
SAFE
56
11 LHIN ANALYSES
LHIN analyses
12 EXAMPLES OF SUCCESS
118
118
138
4.1
Hospital infections
56
4.2
Adverse events in acute care hospitals
60
12.1 Reducing ED waits
138
4.3
Mortality in hospitals
62
12.2 Primary care
140
4.4
Drug safety in long-term care
64
12.3 Surgical wait times
141
4.5
Avoiding harm in long-term care
66
12.4 MRI wait times
142
4.6
Avoiding harm in home care
67
12.5 Chronic disease management
143
12.6 Congestive heart failure readmissions
144
12.7 Ventilator-associated pneumonia,
central line infection and c. difficile infection
145
12.8 Alternative level of care
146
PATIENT-CENTRED
5.1
5.2
70
Patient experience in acute care hospitals and
emergency departments
70
Patient experience in primary care
74
13 Endnotes
147
14 Acknowledgements
159
15 Members of Health Quality Ontario
160
1
1. Introduction and summaries
1.1
Executive summary
Ontarians are fortunate to have a publicly funded healthcare system that
provides a comprehensive range of services for all. To help ensure the
system is working properly, the provincial government has expanded the
mandate of the Ontario Health Quality Council, and to mark this transition,
the organization has registered the name “Health Quality Ontario” (HQO)
under the Business Names Act and now conducts its affairs under this
name. In addition to monitoring all aspects of the system and reporting to
the people of Ontario on its quality, HQO has been charged with supporting
efforts to improve quality across all healthcare settings, making recommendations on standards of care based on clinical practice guidelines and
protocols, and making recommendations on how healthcare services are
funded. All of these activities aim to accelerate the adoption of best
available scientific evidence in the healthcare system.
Our sixth annual report — Quality Monitor — examines Ontario’s healthcare
system with our most critical eye. We note changes for the better or for the
worse and report them to you. More importantly, we compare how we are
doing to the best results elsewhere and provide an opinion about whether
quality is good or needs improvement.
How we completed this report
HQO routinely monitors indicators and data sources used throughout
Ontario, Canada and internationally, and works with its Performance
Measurement Advisory Board to select indicators for this report. Data
is drawn from sources that include Ministry of Health and Long-term
Care (MOHLTC) databases, Census Canada, international surveys from
the Commonwealth Fund and many others. The Institute for Clinical
Evaluative Sciences (ICES) helped us conduct many of the data analyses.
Researchers, clinical experts and healthcare executives reviewed our
findings for accuracy and validity.
Key features of this year’s report
Broader coverage of the nine attributes of quality
The nine attributes that Ontarians tell us reflect a high performing health
system include: accessible, effective, safe, patient-centred, equitable,
efficient, appropriately resourced, integrated and focused on population
health. This year, we have added new indicators to increase our insight into
these nine attributes across all sectors of healthcare. They include:
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primary care
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and depression
Compact format
We describe the entire healthcare system in 35 themes, with approximately
two pages per theme. Most indicators have a mini-graph to indicate
progress or lack of improvement over time and a three-to-five-sentence
description of our interpretation of the data. Information on how indicators
were defined and calculated and more detailed tables of actual data points
can be found in the technical appendix to this report.
2
Mini-summaries for leaders and staff in different sectors and
people with different conditions
There are two-page summaries of key findings for hospitals, LTC, home
care and primary care, as well as brief summaries for cardiovascular
disease, diabetes, mental health and cancer. Each summary includes
questions to ask of leaders or caregivers for self-reflection. Summaries of
key differences for each local health integration network (LHIN) have also
been expanded upon this year.
Root cause analyses and change ideas
Traditional public reporting simply gives indicator results and whether they
are above or below average. Readers, however, are left wondering why
these problems exist and what can be done about them. To counter this,
we have included a root cause analysis with each theme, as well as ideas
for improvement related to the root causes, as identified in the literature.
Best practice stories
We have reported on local stories of improvement, selecting those that had
substantial improvement over the past year and had a clear aim, measures,
change ideas and run charts. These success stories are closely linked to
the key findings of the report, demonstrating that improvement is possible.
Health Quality Ontario’s key findings
This year, Health Quality Ontario (HQO) identified both significant achievements
and significant challenges in Ontario’s healthcare system. Achievements
include reductions in wait times in the emergency department, for many
surgeries and for CT scans, as well as improvements in primary care access,
patient outcomes for coronary artery disease and smoking rates. However,
many of these rates are still far from optimal. Challenges include a continuing
problem with patients occupying alternative level of care (ALC) beds and wait
times that are still too long for long-term care. In addition, Ontario has long
waits for urgent cancer surgeries and specialist appointments and has not
improved patient outcomes for congestive heart failure and chronic
obstructive pulmonary disorder (COPD). In many instances, progress is
linked to a clear strategy to improve results, and lack of progress can be
attributed at least in part to the lack of such a strategy.
Overall, there are several success factors for system-wide quality
improvement, including leadership and accountability, measuring and
reporting on performance, following evidence-based practices, innovative
models and processes for strategic system improvement, ensuring providers
have access to up-to-date training and resources, change management,
patient and family engagement and appropriate capacity throughout the
healthcare system.
Broadly speaking, this report identifies three system areas that need to be
addressed to improve the quality of Ontario’s healthcare system: access to
healthcare, chronic disease management and keeping the population healthy.
It will be critical to have progress across the different success factors and all
three system areas to significantly improve health outcomes and mitigate
healthcare costs. HQO has summarized the province’s achievements and
challenges and indicated specific strategies for improvement for each of the
three system areas below.
1.1 Executive summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Access to healthcare
HQO measures access to healthcare by looking at how long people
have to wait to get the medical attention they need. This year, some
wait time indicators improved dramatically — but big problems remain.
In the emergency department, the 90th percentile length of stay (the
maximum amount of time nine in 10 patients spend in the emergency
department) decreased by two hours for high complexity patients and by
30 minutes for low complexity patients in the past two years. Length of
stay is still well above target for high complexity patients — 12 hours
versus eight hours — but progress has been made. Provincial initiatives
that have contributed to these results include the ED Pay for Results
Program and public reporting of emergency department wait times on the
Ontario Wait Times website. In addition, many hospitals have adopted Lean
process improvements to enhance efficiency and flow, encouraged by the
ED Process Improvement Program (ED PIP).
The average wait time to long-term care (LTC) placement is 3.5 months—
a length of time that is far too high. When people wait in their own homes for
a bed in an LTC home, they may not be receiving all of the care they need
and, as a result, may experience declines in health and quality of life. When
people wait for admission to an LTC home from hospital, that has ripple
effects through the health system. These individuals may be occupying ALC
beds in hospital (i.e. are in hospital even though they are better served
elsewhere), which delays new hospital admissions and can contribute to
increased emergency department wait times. Indeed, one in six people in
hospital are ALC. This problem has not been improving as of 2009/10, and
represents a major inefficiency in the system.
Although LTC wait times are still far too high, they have stopped increasing
for the first time since 2005. This is a promising trend, but it is everyone’s
expectation that these rates now must start to decrease. Going forward,
it will be important to address all aspects of this complex problem and to
ensure adequate resources exist to support providers and patients at every
level of the healthcare system — in hospital, at home and in LTC. It will also
be important for Ontario to evaluate the Aging at Home Strategy, in place
since 2007, which makes a wider range of home care and community
support services available to enable people to continue leading healthy
and independent lives in their own homes.
When it comes to primary care, Ontario has seen steady improvement in the
percentage of people with a family doctor since 2005 and now ranks among
the best in Canada. This is likely due in part to investments in medical schools
that increased the number of spots available, the introduction of health
professionals such as nurse practitioners who can take on some physician
responsibilities, the establishment of family health teams and the expansion of
community health centres. However, 6.5% of adult Ontarians don’t have a
family doctor and 3.3% are actively seeking one. These percentages are even
higher for people with lower incomes and those who live in northern Ontario.
The province also needs to do a better job of making sure people can schedule
an appointment quickly. Fewer than half of Ontarians who were sick were able
to book time with their doctor on the same or next day. There have been no
changes in recent years, and both Canada and Ontario rank poorly on this
indicator compared to other countries.
The situation is even more serious for wait times to see a specialist. Half
the people who are referred to a specialist wait four weeks or longer for an
appointment. Canada’s and Ontario’s standings are the worst among 10 major
developed countries and need to improve.
Ontario is getting better at completing a range of surgeries and other
procedures within provincially mandated targets, despite increasing demand.
The 90th percentile wait times for hip replacements, knee replacements and
cataract surgeries have been cut by more than half since 2005. Meanwhile,
the 90th percentile wait time for CT scans has decreased from 2.5 months to
about one month over the same time period. Ontario’s improvements in wait
times for surgeries and other procedures can be attributed to public reporting
on the Ontario Wait Times website, creation of a provincial information system
to track wait times, funding for increased volumes of surgeries and investments
in new CT equipment. That said, there is still room for improvement in
two important areas. The 90th percentile wait time for cancer surgeries
decreased from 2005 to 2008, but hasn’t improved in the past two years
and currently sits at 51 days. The 90th percentile wait time for MRI scans
has remained at about four months since 2005 (113 days in 2010), despite
huge increases in the number of scans performed. In the future, it will be
important to ensure CT and MRI scans are done only when needed.
Strategies for improvement
In the emergency department, change ideas include developing better
care coordination and moving patients to the right place as soon as possible
so they are not occupying beds unnecessarily. In addition, hospitals can
make specific process improvements within the emergency department,
including creating a fast-track area for less serious cases and changing the
location of supplies and equipment to maximize efficiency. They can divert
non-urgent cases away from the emergency department to other alternatives.
And the system as a whole can focus on improving primary care services so
patients are less likely to require emergency care. For more information, see
section 2.1.
To shorten wait times for long-term care homes, the province needs to
ensure that enough supportive housing and assisted living facilities are
available as an alternative to LTC for people who are able to live more
independently — especially in high-demand regions. Home care needs to be
more available as well, with flexibility on the hours allotted to families based
on their needs. In addition, when patients enter hospital, it’s important to
avoid jumping to the conclusion that they need LTC until they have been
given time to recover, and to keep them as active as possible to prevent a
decline. For more information, see section 2.4 and 6.2.
To maximize primary care and specialist capacity, providers can
take many measures, including adopting advanced access scheduling,
improving office efficiency and implementing a well-functioning electronic
medical record (EMR) system. For more information, see section 2.2.
Part of the solution to the wait time challenge for surgeries and other
procedures is prevention. If Ontario can slow down deterioration of health so
that the need for surgery is reduced, this can have a positive impact on wait
times. There are also major opportunities to streamline the scheduling and
organization of services to reduce wait times, as has been done successfully
in many centres. Other change ideas include implementing appropriate criteria
to ensure that patients truly require surgery or a specific test, and ensuring
at least some excess capacity for services to help handle fluctuations in
demand. For more information, see section 2.3 and 6.3.
3
1. Introduction and summaries
1.1
Chronic disease management
Ontario has had mixed results when it comes to chronic disease
management. The province has experienced steady improvements in
the management of coronary artery disease and can be cautiously
optimistic about diabetes, thanks to reductions in hospital admissions
and complications. However, congestive heart failure and COPD remain
significant challenges. For more information about chronic diseases in
Ontario, see the Disease Summaries sections in this chapter.
In the area of coronary artery disease, heart attack mortality within 30 days
and between 30 days and one year have decreased over the past seven years.
About half as many people per capita are readmitted to hospital following a
heart attack. One-third as many people per capita are admitted to hospital for
angina. There is strong scientific evidence that access to revascularization
(cardiac bypass or stent) can reduce mortality and disability for people who
need this type of care, and Ontario has a highly structured regional system for
delivering these services. The appropriate use of drugs such as statins may
also be contributing to these improvements.
Use of statins and angiotensin-converting enzyme inhibitors (ACEIs)/
angiotensin-receptor blockers (ARBs) has also improved among elderly people
with diabetes, with the application of both at once nearly doubling over the
past seven years. This may be a factor in the one-quarter decrease in hospital
admission rates and nearly one-third decrease in serious complication rates
(within a year) people with diabetes have experienced over the past seven
years. On the other hand, when it comes to on-going management of
diabetes, there has been no improvement in the percentage of people with
diabetes who had an eye exam in the past 12 months. This number is
stagnant at one in two.
Furthermore, there has been only a slight decline in hospitalizations for
congestive heart failure in the past four years (down to 52 from 54 per
100,000 people). About one in five people are readmitted for congestive
heart failure, and this number has not changed at all over the same time period.
Finally, more than one in three patients admitted to hospital for congestive heart
failure die within a year, and this indicator has not improved in seven years.
Similarly, there has been just a slight improvement in COPD hospital admission
rates in the past four years (down to 84 from 92 per 100,000 people), and
COPD is now the most common ambulatory care sensitive condition — where
appropriate care in the community may prevent hospitalization. As with
congestive heart failure, there has been little change in readmission rates in
the past four years. About one in five people are readmitted for COPD.
4
A coordinated strategy, such as the one in place for revascularization
(bypass or stent), could be beneficial in tackling other areas, including
congestive heart failure and COPD.
Strategies for improvement
Disease registries can help practitioners better monitor how well patients
with chronic diseases are doing and provide timely follow-up. Such a registry
is an important part of the province’s Diabetes Strategy. In addition, flow
sheets in patient charts, reminder systems and well-functioning EMRs can
help healthcare providers deliver more consistent care to improve chronic
disease management.
People with chronic conditions can benefit from access to professionals with
special skills, including pharmacists to review their medications, dietitians to
provide advice on nutrition and primary care providers to monitor key health
indicators. The best case is when people have access to a team that meets
all their health-related needs and engages them in self-management by helping
them develop their own action plans and set personal goals. For more
information, see section 3.2.
Meanwhile, making sure that patients receive the right medications while they
are in hospital and after they are discharged can, as already discussed, help
with the management of coronary artery disease and diabetes. Hospitals can
increase the availability and use of standardized admission orders, discharge
checklists, order sets or electronic health records (EHRs) that guide clinicians’
decisions and generate clinical reminders. Also critical to a smooth transition
from hospital back into the community is ensuring the seamless transmission
of patient information to the primary care provider — ideally directly into the
patient’s EMR. For more information, see section 3.1 and 8.1.
These are elements of a comprehensive chronic care model.
For more information about Ontario’s framework for preventing
and managing chronic disease, see
www.health.gov.on.ca/english/providers/program/cdpm/index.html.
1.1 Executive summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Keeping the population healthy
Strategies for improvement
One of the best ways to manage healthcare costs is to implement
effective programs that help keep the population healthy. Ontario
has had major success in reducing the smoking rate by 25% since
2001, but continues to struggle to improve physical activity and
reduce obesity.
Toronto stepped up ahead of the rest of the province to prohibit smoking in
most public places and workplaces (1999), then in restaurants, dinner theatres
and bowling centres (2001), and finally in bars, billiard halls, bingo halls,
casinos and racetracks (2004). Toronto currently has the province’s lowest
smoking rate, at 13%, so it appears these types of measures are effective.
Policy changes such as the 2006 Smoke-Free Ontario Act have likely
contributed to a steady decline in smoking rates and exposure to second-hand
smoke over the past six years, and Ontario is now among the best-performing
provinces in Canada on these indicators. The current provincial smoking rate is
19%, however, meaning that nearly one in five people across Ontario continue
to smoke. Furthermore, people with low incomes or less education are twice as
likely to smoke as people with high incomes or a post-secondary education.
More needs to be done to address these specific population groups.
Other change ideas include improving access to smoking cessation
programs, making it easier for people to use nicotine replacement
therapies, “de-normalizing” unhealthy behaviours and addressing the range
of constraining and enabling factors that influence peoples’ health and
access to care. It will also be important to close knowledge and awareness
gaps and make sure healthy choices are obvious and accessible. The
Ministry of Health Promotion and Sport will have an important role to play
in these types of initiatives. For more information, see section 9.1.
The rate of obesity has increased from 16% to 18% over the past eight years.
Just one in two Ontarians get enough exercise and this number has remained
the same since 2007. Finally, fewer than half get the recommended five or
more servings of fruits or vegetables every day, with no major improvement
since 2003. A coordinated obesity strategy may be part of the solution.
To improve prevention, it may be helpful to develop provincial registries and
EMRs/EHRs to remind patients when they are due for screening tests, to
encourage adherence through public awareness campaigns and culturally
sensitive screening programs, and to reach out to vulnerable and hard-to-reach
populations through mobile care units and access to vaccinations outside
primary care offices. For more information, see section 9.4.
Early screening for illness is another important component of population
health. Ontario’s aggressive ColonCancerCheck campaign targeted
screening for one disease that can be much more successfully treated
when caught early. Screening for colon cancer has increased by 68% in the
last four years, with nearly one in three people aged 50 to 74 taking a fecal
occult blood test in 2009. However, many other types of screening can
help the province detect additional diseases sooner, treat them earlier and
improve people’s survival rates.
As already suggested in relation to smoking, there are still huge inequalities in
the province. For example, income levels affect the likelihood of having a heart
attack, with the poorest Ontarians 36% more likely to experience an acute
myocardial infarction than the richest Ontarians. Meanwhile, the lowest-income
Ontarians have a 32% higher rate of injury-related hospitalization compared
to the highest-income Ontarians. Ontario is still a long way from achieving
equitable health outcomes.
i
Other provinces sometimes have ideas that may translate well to Ontario. In
British Columbia, as just one example, it has been suggested that the province
limit marketing of unhealthy food and beverages to children, add nutritional
labeling on menus, tax unhealthy choices, expand wellness programs in the
workplace and revitalize recreation facilities, among other measuresi.
Finally, as recommended last year, strategies tailored to the most vulnerable
populations may speed up progress on chronic diseases and help to improve
equity in the province’s healthcare system. Making it easier for lower-income
individuals to access healthy food, offering free physical activity programs
and implementing healthy community initiatives can contribute to a healthier
province and lower healthcare costs over the long term.
BC Healthy Living Alliance, “Healthy living in BC — the next generation.” January 2011. www.bchealthyliving.ca.
5
1. Introduction and summaries
1.2
Quality improvement summary
KEY SUCCESS FACTORS FOR SYSTEM-WIDE
QUALITY IMPROVEMENT
The Quality Monitor identifies not only problems with quality, but also
the root causes of these problems and ideas for improvement. For each
individual indicator, specific ideas have been identified from the scientific
literature, best practice stories and successful quality improvement
campaigns around the world. These ideas fall into several broad categories
of success factors for system-wide improvement identified below. Ensuring
that all of these success factors are adopted in a coordinated fashion
is essential.
1. Leadership and accountability
“The strategic plan? Isn’t that something to do with head office?”
“We had great ideas for improvement, but no one listened to us!”
A recurring theme in this report is the need to streamline processes.
Specific examples include eliminating redundant steps, standardizing
processes, doing things in parallel instead of in sequence, making
processes error-proof, making defects easy to spot and fixing them
early before they are passed on. Teamwork can be strengthened by
establishing good processes for handing off care, consistent routines
for communication and role clarity.i
Many healthcare organizations are now using process improvement
methods such as Lean (elimination of waste) and Six Sigma (elimination
of defects). It is important to ensure that organizations have staff with
deep expertise in the use of quality improvement methods who can
mentor or lead process improvement activities.
3. Measurement and reporting
Change is hard. Change can generate fear of the unknown. Changes that
result in a shift in roles can generate resistance, if one group perceives it
as a loss. Successful change requires strong leadership that involves:
“I thought we were doing a great job until I saw our data.”
t $SFBUJOHBDPNQFMMJOHWJTJPOGPSRVBMJUZBOETQFDJmDUBSHFUTBOE
timeframes for completion that describe that vision in tangible terms.
Leaders can communicate the vision and inspire people to achieve it.
t %FTDSJCJOHBDMFBSTUSBUFHZ5IJTJOWPMWFTJEFOUJGZJOHUIPTFBDUJWJUJFT or evidence-based best practices that have the biggest impact.
Leaders set clear expectations and clear accountability for all levels
of the organization for implementing these activities, where each
individual understands his or her role in achieving the vision.
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learning, trying new ideas, and being encouraged to report quality
problems instead of being punished. Leaders develop conflict
management skills in the organization to manage resistance. Leaders
engage people at the front line in the change process. Leaders
find champions to promote change among their peers (especially
important for physicians). Lastly, leaders celebrate successes and
facilitate the sharing of best practices.
Quality measurement helps identify areas that need improvement, make the
case for change, identify the root cause of problems, and monitor whether
an intervention to improve quality is working. Ontario has a wealth of data
on quality, but there are still huge gaps to be filled (see the data advocacy
section, see 1.12). Reporting this information to the public is important,
because public comparisons between institutions can spur leaders to outdo
their peers. Although Ontario already reports on many wait times and safety
indicators by institution, there are other opportunities to expand public
reporting further.
2. Well designed processes, systems and teamwork for
delivering healthcare
“I can’t find those lab results — just run the test again.”
“Why do I have to give the same information to five
different people?”
Healthcare is a complex system that involves many tasks carried out
by different people in different organizations. Every time one provider
hands off care to the next, errors or miscommunication can occur. Over
time, some steps become redundant. Often, sequences of tasks differ
among different organizations, individuals, or even different floors or shifts
within one organization. This creates confusion or delay, and leads to
inconvenience, waste, poor care or harm.
“You can’t manage what you can’t measure.”
Ontario, however, is weak in its ability to provide instant feedback on quality
performance to individual health care providers or teams. This feedback is
essential to getting people engaged about quality and to allow improvement
teams to change their strategy if it is not working. Developing instant
feedback will require that electronic health records are carefully designed
for this purpose.
4. Tools to address information overload
“Trying to keep up with the literature is like drinking from
a fire hose.”
In 2009, 1.5 million articles were published in the area of science,
technology and medicine.ii
Today’s healthcare providers are bombarded with information. Best
evidence often isn’t followed, resulting in poorer outcomes and wasted
resources. This can be because people forget (the brain has natural limits
on memory) or there are distractions (too many competing demands for
attention), no time to read all the evidence, and difficulty applying different
guidelines simultaneously to complicated patients with different conditions.iii
Practice guidelines tell providers what to do, but cannot change practice on
their own.
i
Ontario Health Quality Council. Improvement guide. 2009. www.ohqc.ca/pdfs/qi_guide.pdf; accessed February 25, 2011.
ii
Ware M, Mabe M. The STM report. An overview of scientific and scholarly journal publishing. International Association of Scientific, Technical and Medical Publishers, 2009.
iii
Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004;180(6 Suppl):S57-60.
6
1.2 Quality
1.1improvement
Exective Summary
summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Practice tools can help address these problems. They include checklists,
standardized care orders, flow sheets, appropriateness criteria, reminder
systems and other decision support tools. These tools can be verbal,
paper or electronic-based, and can prompt providers to perform or avoid
a particular action, help decide on a drug or test, or document if a best
practice was followed.
5. Verifying and upgrading providers’ clinical skills
“When was the last time you did that procedure?”
“I’ve lost my touch…”
Clinical skills are the ability of health care providers to evaluate a clinical
problem or execute a task that may require knowledge, critical thinking,
experience or technical skills. There may be gaps in skills if: the original
training was inadequate; the task is done infrequently and skills deteriorate
over time (“use it or lose it”); the technique changes but there is no opportunity
to upgrade skills; or, there is no mechanism to spot and fix problems with
clinical skills. Traditional activities like lectures do not address well these
problems. Other approaches include: formal recertification programs; direct
observation of providers performing specified tasks when the technique is
taught, when staff are hired, and at regular intervals); and patient simulation
labs. Planners can also organizing care so that certain services are delivered
only by institutions or individuals that maintain a minimum volume.
6. Patient and family engagement
“No one ever told me about my options!”
7. The right policies and incentives for quality
“Is there any reason why we should do things differently?
Why should I change?”
Incentives and policies can motivate change. People want to improve quality if
they are recognized and appreciated for their efforts; can see tangible results;
and feel supported. Providers embrace quality improvement initiatives when
the outcome is not only better clinical care but also reduced wasted time or
administrative hassle. “Herd behaviour” is important for both patients and
providers. Seeing a peer choose the right treatment can influence a provider
to do the same. For patients, policies like smoking bans which “de-normalize”
unhealthy behavior appear to be effective. Policies on how services are funded
represent another lever for change. Many believe that funding should be tied
to quality. For example, extra costs resulting from poor quality should be
borne by the organization that provided and was funded for that care.v
8. The right capacity throughout the healthcare system
“Why do we have wait lists for some services and but not for others?”
Supply and demand for services need to be matched to reduce both waste
and unnecessary wait times. The health care system needs to be constantly
estimating what the future demand is for different type of services in different
communities and then making sure it has the right amount of equipment,
programs or healthcare providers to meet this demand. When managing wait
lists, it is best to have at least some excess capacity to allow the system to
handle random surges in demand. Estimates of demand should also consider
opportunities to reduce demand, through better prevention and reduction of
inappropriate use of services.
Quality improvement depends on patients being engaged in their care. This
means that they understand the importance of healthy living and the nature of
their illnesses. They know their treatment options and make informed choices
which fit their preferences and lifestyle. They feel encouraged to ask the right
questions about their care — what is happening to them and why, and are not
afraid to point out problems with their care (e.g. when someone forgets to
wash their hands). Patient education and health promotion are helpful but even
more powerful are patient self-management skills.iv When individuals feel they
are in control of their health, they are more likely to continue taking the right
drugs or adopt healthy living habits.
Health and health behaviours are generally worse for people with low income
or education, or in certain communities. It is important to ensure that patient
engagement activities are tailored to these groups as well as those from
different language or cultural groups, and that these activities are coordinated
with other activities that address broader determinants of health (e.g. housing,
employment, healthy communities).
iv
Coleman MT, Newton KS. Supporting self-management in patients with chronic illness. Am Fam Physician. October 15, 2005;72(8):1503–1510.
v
www.leapfroggroup.org/for_hospitals/leapfrog_hospital_quality_and_safety_survey_copy/never_events. Accessed April 14, 2011.
7
1. Introduction and summaries
1.3
1.2
Attributes framework
The attributes of a high-performing health system.
ONTARIANS WANT THEIR HEALTH SYSTEM TO BE:
ACCESSIBLE
APPROPRIATELY RESOURCED
People should be able to get timely and appropriate healthcare
services to achieve the best possible health outcomes. For example,
when a special test is needed, you should receive it when needed and
without causing you extra strain and upset. If you have a chronic illness
such as diabetes and asthma, you should be able to find help to manage
your disease and avoid more serious problems.
The health system should have enough qualified providers, funding,
information, equipment, supplies and facilities to look after people’s
health needs. For example, as people age they develop more health
problems. This means there will be more need for specialized machines,
doctors, nurses and others to provide good care. A high-performing health
system will plan and prepare for this.
EFFECTIVE
INTEGRATED
People should receive care that works and is based on the best
available scientific information. For example, your doctor (or healthcare
provider) should know what the proven treatments are for your particular
needs including best ways of coordinating care, preventing disease or
using technology.
All parts of the health system should be organized, connected and
work with one another to provide high quality care. For example, if
you need major surgery, your care should be managed so that you move
smoothly from hospital to rehabilitation and into the care you need after
you go home.
SAFE
FOCUSED ON POPULATION HEALTH
People should not be harmed by an accident or mistakes when they
receive care. For example, steps should be taken so that elderly people
are less likely to fall in long-term care homes. There should be systems
in place so you are not given the wrong drug, or the wrong dose of a drug.
The health system should work to prevent sickness and improve
the health of the people of Ontario.
PATIENT-CENTRED
Healthcare providers should offer services in a way that is sensitive
to an individual’s needs and preferences. For example, you should
receive care that respects your dignity and privacy. You should be able to
find care that respects your religious, cultural and language needs and your
life’s circumstances.
EQUITABLE
People should get the same quality of care regardless of who they
are and where they live. For example, if you don’t speak English or
French it can be hard to find out about the health services you need and to
get to those services. The same can be true for people who are poor or
less educated, or for those who live in small or far-off communities. Extra
help is sometimes needed to make sure everyone gets the care they need.
EFFICIENT
The health system should continually look for ways to reduce waste,
including waste of supplies, equipment, time, ideas and information.
For example, to avoid the need to repeat tests or wait for reports to
be sent from one doctor to another, your health information should be
available to all of your doctors through a secure computer system.
8
1.4 Hospital sector summary
HOSPITAL
1.4
Hospital sector summary
LONG-TERM CARE
ACUTE CARE HOSPITALS: summary for boards, CEOs, senior management and clinical leaders
HOME CARE
PRIMARY CARE
Topic area
Key facts
Questions to consider
1. ALC
(section 6.2)
t "QQSPYJNBUFMZPOFJOTJYIPTQJUBMCFETJO0OUBSJPBSFmMMFE
with patients who should be cared for somewhere else. This
problem has not improved in the last year (2009/10). This
represents a major inefficiency in the health care system.
t "SFXFXPSLJOHXJUIDPNNVOJUZDBSFBDDFTTDFOUSFT$$"$T
UPBQQMZ
the Home First approach, where frail individuals admitted to hospital
go home with the necessary home care support, where they can then
make a decision about whether they need to be in a LTC home?
t $BOXFJEFOUJGZQFPQMFBUSJTLGPSCFJOH"-$FBSMJFSFHXIFOUIFZ
visit the emergency department for the first time), so that home care
services can be arranged before their health deteriorates?
t "SFXFVTJOHSFIBCJMJUBUJPOSFTPVSDFTUPIFMQQBUJFOUTSFHBJOUIFJS
function and return home to live as independently as possible?
t "SFXFXPSLJOHXJUI$$"$TBOEMPDBMIFBMUIJOUFHSBUJPOOFUXPSLT
(LHINs) to promote supportive housing models or similar options for
frail individuals?
t 8IBUBSFUIFDIBSBDUFSJTUJDTPG"-$QBUJFOUTUIBUBSFEJGmDVMUUP
place into LTC homes? What services need to be developed in the
community or in LTC homes to serve them?
2. Emergency
department
(ED)
wait times
(section 2.1)
ED wait times have improved but are still well short of provincial
targets. It is the admitted patients who are least likely to be
admitted within the recommended timeframe. Specifically:
t "SFXFNPWJOHQBUJFOUTXIPEPOPUOFFEUPCFSFDFJWJOHDBSFJOUIF
hospital to the right place as quickly as possible (see above)?
t )BWFXFDPOTJEFSFEBMMUIFEJGGFSFOUJEFBTGPSJNQSPWJOHQBUJFOUnPX
within the ED (e.g., fast-track area for less serious cases, improved
layout by changing the location of supplies and equipment to maximize
efficiency, chairs for acute patients, flexible human resources scheduling
and information systems to track patients and results)?
t %PXFIBWFBPSHBOJ[BUJPOXJEFDPOUJOHFODZQMBOXIFOUIF&%SFBDIFT
critical gridlock?
t )BWFXFDPOTJEFSFEEJWFSUJOHOPOVSHFOUDBTFTBXBZGSPNUIF&%UP
alternatives that are most appropriate for their conditions? Are we
redirecting people who are using the ED for their main source of care
to family doctors who are taking new patients?
t $BOXFXPSLXJUIPUIFSTUBLFIPMEFSTUPJNQSPWFQSJNBSZDBSFTFSWJDFT
so patients are less likely to need ED care?
3. Surgical and
CT/MRI wait
times
(section 2.3)
Wait times have decreased for many procedures overall, but
there is still room to improve, especially for high-priority cases
for all surgeries (particularly cancer) and MRI. Specifically:
t 5IFNBYJNVNUJNFOJOFJOQBUJFOUTTQFOEJOBO&%
decreased in the last two years by two hours for high
complexity patients (from 14 to 12 hours), and by half
an hour for low complexity patients (from 4.8 to 4.3 hours).
The target is 8 and 4 hours respectively.
t 0OFJO0OUBSJBOTXIPWJTJUUIFFNFSHFODZEFQBSUNFOU
leave without being seen by a physician, likely because they
were tired of waiting. This figure has been improving.
t "NPOHQBUJFOUTBENJUUFEUPIPTQJUBMGSPNUIF&%IBMGPG
them waited more than three hours for a bed, and this has
not improved in the past two years. Also, only 41% of these
patients are served within the recommended timeframe,
compared to 81% overall.
t 0OUBSJPBOE$BOBEBGBSFQPPSMZPOJOUFSOBUJPOBMDPNQBSJTPOT
of ED waits.
t 5IFth percentile wait for hip or knee replacement is just
under seven months; for cataracts, four months; and for CT
scans, one month. Waits are less than half of what they were
in 2005.
t 5IFth percentile wait for MRI is four months — same as
it was in 2005, despite a nearly three-fold increase in the
number of scans being done.
t *OUIFDBTFPGHFOFSBMTVSHFSZBOETVSHFSZGPSDBODFS
cataracts, coronary artery bypass, angiography and
percutaneous coronary intervention (e.g. cardiac
stents), 93% to 99% of elective cases are done within
the recommended time frame. However, for urgent cases,
the percentage done within the recommended time is much
lower: for cancer,67%; cataract, 66%; general surgery, 83%;
coronary bypass, 86%; angiography, 85%; percutaneous
coronary intervention, 85%.
t $5BOE.3*TDBOTBSFFYDFQUJPOTUPUIFBCPWFUSFOEVSHFOU
cases are more likely to be done within the recommended
time frame than elective cases.
t "SFUIFSFQPPSIBOEPGGTQPPSDPNNVOJDBUJPOPSMBDLPGTUBOEBSEJ[FE
processes that contribute to delays?
t %PXFIBWFBQQSPQSJBUFDSJUFSJBUPFOTVSFUIBUQBUJFOUTUSVMZSFRVJSF
surgery or tests?
t $BOXFFOTVSFBUMFBTUTPNFFYDFTTDBQBDJUZGPSTFSWJDFTBTTPDJBUFE
with surgery (such as space in the intensive care unit)?
t )BWFXFDPOTJEFSFEDFOUSBMJ[FECPPLJOHTZTUFNTUIBUDPVMEDPOOFDU
patients to places with the shortest wait time?
t %PXFNPOJUPSLFZQSPDFTTNFUSJDTFHPOUJNFDBTFTUBSUTBOE
downtime) so we can maximize our efficiency and increase our capacity?
t %PXFNFBTVSFEFNBOEBOETVQQMZBOEEPXFLOPXJGUIFZBSF
in balance? Have we ever done queue-clearing blitzes — for example,
temporarily increasing the rate of procedures done until backlog
is eliminated?
9
1. Introduction and summaries
1.4
Access to Primary Care
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
Topic area
Key facts
Questions to consider
4. Safety —
hospital
infections and
other areas
(sections 4.1,
4.2 and 4.3)
Hospital-acquired infections have improved but there is major
room for improvement.
t )PXXFMMBSFXFGPMMPXJOHTUBOEBSEQSPUPDPMTGPSQSFWFOUJOHWFOUJMBUPS
associated pneumonia and central line infections? Is anyone deviating
from the protocol, and why?
t 8IBUBSFXFEPJOHUPFOTVSFUIBUBMMTUBGGBOEQIZTJDJBOTVTFQSPQFS
hand washing techniques? Are we auditing hand hygiene frequently
(more than just once a year) and providing feedback to staff on
compliance (e.g., monthly or quarterly, by ward or by provider group)?
Are hand washing stations conveniently located, never empty, and
being used? Are we encouraging patients to ask providers if they’ve
washed their hands?
t "SFXFSFHVMBSMZVTJOHDIFDLMJTUTTUBOEBSEJ[FEPSEFSTFUTPSQSPUPDPMT
to minimize reliance on memory? If so, are we actually tracking how
we’re using them and if they are having an effect?
t "SFXFFODPVSBHJOHQBUJFOUTUPBTLRVFTUJPOTBCPVUTBGFUZ
t "SFXFQSPNPUJOHBDVMUVSFPGTBGFUZXIFSFQFPQMFGFFMGSFFUPTQFBL
up if they see a safety issue?
t %PXFIBWFQIZTJDJBODIBNQJPOTGPSTBGFUZ
t "SFXFDPOTJEFSJOHUIFVTFPGSBQJESFTQPOTFUFBNTXJUIDMFBS
guidelines for when they are to be used?
5. Effectiveness/
evidencebased
practices
(section 3.1)
t "MUIPVHIUIFSFIBTCFFOTPNFJODSFBTFJOUIFQFSDFOUBHF
of patients filling prescriptions upon discharge for heart attack and congestive heart failure, there is still room to
improve. Hospitals who do not do this well tend to have
higher readmission rates.
t "MUIPVHIUIFSFIBWFCFFOHBJOTPWFSUIFQBTUTJYZFBSTPOMZ
one in eight patients who has a stroke and could benefit from
clot-busting drugs receives those drugs within one hour of
arriving in the emergency department.
t %PXFIBWFJOGPSNBUJPOUFDIOPMPHZTZTUFNTJOQMBDFUPSFNJOE
doctors of standard protocols and treatment plans or to track
compliance with guidelines?
t "SFXFVTJOHDIFDLMJTUTPSTUBOEBSEJ[FEPSEFSTFUTUPNBLFTVSF
people with different conditions (e.g. heart attack, heart failure,
stroke) get the right drugs and tests?
t "SFXFFEVDBUJOHQBUJFOUTPOUIFJNQPSUBODFPGUIFTF
medications and how to take them?
t %PXFIBWFBTUBOEBSEJ[FEQSPDFTTGPSIBOEMJOHUJNFTFOTJUJWF
situations like a new stroke? If so, how well are we following it?
6. Readmissions
(section 3.3)
t "CPVUPOFJOmWFQBUJFOUTXJUIDPOHFTUJWFIFBSUGBJMVSFPS
COPD are readmitted within a month, for any cause. There
is huge room to improve these rates.
t 3FBENJTTJPOTPWFSUIFQBTUTFWFOZFBSTIBWFEFDSFBTFECZ
almost half for heart attack, which is good news.
t %PXFLOPXXIZPVSQBUJFOUTBSFCFJOHSFBENJUUFE t *OGFDUJPOSBUFTGPSC. difficile remained stable in the last year
after gains in the previous year.
t 0OUBSJPIPTQJUBMTEFDSFBTFEUIFOVNCFSPGDBTFTPG
ventilator-associated pneumonia and central line infection
from January 2009 to September 2010, but have not yet
reached the desired level of zero.
t 5XPJOUISFF0OUBSJPIFBMUIDBSFQSPWJEFSTXBTIUIFJSIBOET
before seeing patients, while almost eight in 10 wash their
hands after patient contact. There have been improvements,
but these rates are still too low.
t-BTUZFBSBMNPTUTFWFOJOSFQPSUBCMFIPTQJUBMT
experienced a decrease in their hospital standardized
mortality ratio (HSMR) score, which is encouraging.
t 5PSFEVDFSFBENJTTJPOBSFXFNBLJOHTVSFQBUJFOUTIBWFBMMUIF
information they need when they are sent home (see below)?
t %PQBUJFOUTBUIJHISJTLGPSSFBENJTTJPOIBWFBGPMMPXVQIPNF
care visit immediately after discharge and an appointment with
their doctor soon after discharge (e.g. a week)?
t )PXRVJDLMZBSFXFUSBOTGFSSJOHEJTDIBSHFTVNNBSJFTUP
family physicians?
7. Discharge
hand-offs
(section 8.1)
and
communication
(section 5.1)
Many patients leave hospital without the information they need,
which can lead to readmissions. For example:
t 0OMZIBMGPGIPTQJUBMQBUJFOUTLOPXXIFOUPSFTVNF
normal activities
t 0OMZIBMGPG&%QBUJFOUTLOPXXIBUEBOHFSTJHOTUPMPPL
out for at home
t "CPVUPOFJOUISFFQBUJFOUTEPOPULOPXXIBUTJEFFGGFDUT
of medications to look for
There are general problems with communication:
t "CPVUPOFJOUISFFQBUJFOUTGFMUUIBUTUBGGEJEOPUQSPWJEF
explanations to questions that were understandable
10
t "SFXSJUUFOEJTDIBSHFJOTUSVDUJPOTSPVUJOFGPSBMMPGPVSQBUJFOUT
(including warning signs, whom to call, etc.)?
t %PXFVTFNFUIPETMJLFiUFBDICBDLwUPWFSJGZQBUJFOUT
understand all the information they have been given?
t 8IBUBSFXFEPJOHUPTJNQMJGZDPNNVOJDBUJPOUPQFPQMFXJUIMPX
literacy? Do we have translators for people who speak different
languages?
1.4 Hospital sector summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Topic area
Key facts
Questions to consider
8. Patient
experience
(section 5.1)
Pain control and responsiveness can be improved.
t "SFXFGPMMPXJOHTUBOEBSEQSPDFEVSFTBOECFTUQSBDUJDFTGPS
pain control (e.g. monitoring pain like a vital sign; using visual
analogue scales; standard pain protocols; patient-controlled
anesthesia in certain settings)?
9. Hospital
finances
(section 6.1)
t PGIPTQJUBMTSFQPSUFEBEFmDJUJO':"NPOH
large community hospitals, 36% reported a deficit.
t 4PNFIPTQJUBMTFTQFDJBMMZMBSHFDPNNVOJUZBOEUFBDIJOH
hospitals) continue to struggle to manage their current ability
to pay bills without having to borrow.
t "CPVUPOFJOUXPQBUJFOUTGFMUTUBGGEJEOPUEPFWFSZUIJOHUIFZ
could to control pain
t "CPVUPOFJOUISFFFYQSFTTFEDPODFSOBCPVUUJNFMJOFTTPG
requests for help (e.g. assistance to go to the bathroom,
response to a call button).
t 8IJMFUIFmSTUJOTUJODUXIFOGBDJOHBEFmDJUJTUPDVUTFSWJDFTIBT
hospital management carefully thought of all the different sources
of waste in the system and made aggressive plans to eliminate
them (e.g., unnecessary tests or services and waste of staffing,
space, inventory and supplies)?
11
1. Introduction and summaries
1.5
1.2
Primary
summary
Access tocare
Primary
Care
PRIMARY CARE: summary for primary care practitioners
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
Topic area
Key facts
Questions to consider
1. Access to
primary care
(see section
2.2)
There has been important progress in ensuring Ontarians
have a regular doctor, but wait times to get an appointment
are too long.
t "SFXFVTJOHBEWBODFEBDDFTTUIFTZTUFNPGTDIFEVMJOH
appointments and managing patient flow to reduce or eliminate
wait times for appointments?
t $PVMEXFSFEVDFVOOFDFTTBSZSFQFBUWJTJUTUPGSFFVQNPSFUJNF
to serve people better (e.g., by giving lab results over the phone
instead of requiring a visit)?
t "SFPVSQSPDFTTFTBTFGmDJFOUBTUIFZDPVMECF 'PSFYBNQMF
is each exam room set up exactly the same way? Can things be
relocated to reduce walking around?
t %PXFIBWFBXFMMGVODUJPOJOHFMFDUSPOJDNFEJDBMSFDPSE
(EMR) system?
t "SFXFXPSLJOHJOBUFBN *GZFTBSFXFVTJOHFBDIUFBN
member to his/her fullest capacity? Are each team member’s
roles and responsibilities clear? What tasks could be shifted
from one team member to another?
2. Access to
surgery, CT/
MRI scans
and specialist
care
(see section
2.3)
t 8BJUUJNFTIBWFEFDSFBTFEGPSNBOZTVSHFSJFTMJLFIJQBOE
knee replacements and cataracts, and for CT scans. There
is still room to improve, especially for high-priority cases for
all surgeries (particularly cancer) and MRI.
t )BMGUIFQFPQMFXIPBSFSFGFSSFEUPBTQFDJBMJTUXBJU
four weeks or longer for an appointment. Canada’s
and Ontario’s standings are the worst among 10 major
developed countries.
t 'PS$5.3*TDBOTBSFBMMUIFUFTUTXFBSFPSEFSJOHOFDFTTBSZ Do we find ourselves pressured into ordering tests that are not
needed? What could we do about that?
t %PXFVTFUIF0OUBSJP8BJU5JNFTXFCTJUFUPmOEQMBDFTUIBUDBO
do a surgery sooner if the patient wants this?
t )BWFXFEPOFBMMXFDBOUPFODPVSBHFQBUJFOUTUPBEPQUHPPE
health behaviours to avoid surgery (e.g. lose weight to avoid
knee replacement)?
3. Wait times
from the
community
to long-term
care (LTC)
(see section
2.4)
t 5IFNFEJBOXBJUUJNFGPSQFPQMFQMBDFEJOUPB-5$IPNF
from the community is well over 5 months, which is too long.
t )BWFXFFYQMPSFEBMUFSOBUJWFTUP-5$QMBDFNFOUXJUIQBUJFOUTBOE
families (e.g., assisted living or supportive housing)?
4. Chronic
disease
Management
(see section
3.2 and 3.3
on avoidable
hospitalizations)
There are signs of improvement in chronic disease
management — complications rates of diabetes are
decreasing and heart attack mortality is dropping.
However, there is still room to do better:
t "SFXFVTJOHNFUIPETTVDIBTnPXTIFFUTUPSFNJOEVTPGBMMUIF
best practices?
t *GXFIBWFBO&.3EPFTJUQSPWJEFVTXJUIEBUBPOUIFQFSDFOUBHF
of our patients with diabetes who are on the right drugs (e.g., a
statin, ACEI/ARB and acetylsalicylic acid) and who have received
a recent A1C test or eye exam?
t )BWFXFTFUUIF&.3VQTPJUSFNJOETVTXIFOQBUJFOUTOFFE
tests or follow-up?
t %PBMMPGPVSQBUJFOUTLOPXXIBUUIFJSUBSHFUTBSFGPSHPPE
disease control (e.g., blood pressure < 130/80 for diabetes
or A1C < 7)?
t )BWFQBUJFOUTJEFOUJmFEUIFJSPXOHPBMTGPSJNQSPWJOHUIFJSIFBMUI
(e.g., personal targets for weight reduction)? Have they all been
connected with a chronic disease self-management program?
t %PXFLOPXUIFDPNNVOJUZTVQQPSUTBWBJMBCMFGPSPVSQBUJFOUT
to help them sustain healthy living?
t %PXFSFGFSUIFNPTUDPNQMFYQBUJFOUTUPTQFDJBMJ[FEDMJOJDT
for care of conditions such as diabetes, COPD and congestive
heart failure?
12
t "CPVUPOFJO0OUBSJBOTBSFXJUIPVUBSFHVMBSEPDUPSBOE
almost half of those individuals are seeking one. Over the
past three years, the percentage of adults without a family
doctor has dropped from 8.2% to 6.5%.
t #BTFEPOTVSWFZEBUB0OUBSJBOTBSFNPSFMJLFMZUIBO
people in Quebec and Western Canada to have a regular
primary care provider, and as likely as those in Atlantic
Canada to have one. Internationally, Ontario is on par
with other countries that had the best results among 11
countries surveyed.
t "NPOH0OUBSJBOTXIPBSFTJDLGFXFSUIBOBSF
able to see their doctor on the same or next day after
contacting their doctor’s office. This indicator has not
improved in recent years, and Ontario and Canada are
behind other countries.
t 0OMZBCPVUIBMGPGQFPQMFXJUIEJBCFUFTSFDFJWFEBOFZF
exam in the past 12 months.
t 5IFVTFPG"$&*T"3#TBOETUBUJOTJTJODSFBTJOHBNPOH
elderly people with diabetes but there is still room to
improve, since only half of people are getting both of
these drugs.
t )FBWZESJOLJOHBOEPCFTJUZIBWFCFFOPOUIFSJTFPWFSUIF
past nine years among people with chronic diseases. Rates
of physical inactivity, smoking and inadequate fruit and
vegetable consumption have seen minor improvements in
this timeframe but are still too high.
t 0WFSPOFUIJSEPGQBUJFOUTBENJUUFEUPIPTQJUBMGPSDPOHFTUJWF
heart failure die within the next year. There has been no
improvement in the last six years.
t *O':SPVHIMZQFPQMFXFSFBENJUUFE
to hospitals in Ontario for complications from chronic
diseases that could have been prevented with good
primary care. COPD and congestive heart failure are
the two most common conditions associated with these
hospital admissions.
1.5 Primary care summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Topic area
Key facts
Questions to consider
5. Efficiency
Only one in six elderly patients with uncomplicated
hypertension receive treatment with diuretics such as
thiazides. The rest are taking medications that are more
expensive and no more effective.
t %PXFIBWFQSPUPDPMTPSEFDJTJPOUPPMTUPHVJEFUIFDIPJDFPG
medications to use? Do they take into account best quality at
lowest cost?
t "SFXFBMMPXJOHESVHDPNQBOJFTUPJOnVFODFPVS
prescribing decisions?
6. EMR adoption
(see section
7.2)
Good progress is being made in introducing electronic medical
records (EMRs) to primary care. It’s important, however, that
EMRs are fully used as a tool to manage quality, rather than just
a place to store information.
t *GXFBSFDPOTJEFSJOHCVZJOHBO&.3TZTUFNBSFXFHFUUJOH
answers from potential vendors on these questions:
- Can it give me a list of all patients with certain
chronic diseases?
- Can it track key indicators, such as percentage of diabetes
patients with A1C under control?
- Will it send reminders when patients need follow-up or tests?
- Can it connect to pharmacies, labs, hospitals and
other providers?
t %PXFIBWFBQMBOUPNJOJNJ[FEJTSVQUJPOTUPXPSLnPXBOE
productivity when implementing an EMR system?
t "TPG4FQUFNCFSNPSFUIBOQIZTJDJBOTIBWF
enrolled in provincial EMR adoption programs that support
physicians to use EMRs. The target is to have 9,000 primary
care and specialist physicians enrolled by March 2012.
t 0OMZPGBEVMUTJO0OUBSJPIBWFFNBJMFEUIFJSGBNJMZ
doctor with a medical question. Both Ontario and Canada
lag behind a number of other countries.
7. Health human
resources
(see section
7.4)
t 'SPNUPUIFSFIBTCFFOBOJODSFBTFJOUIF
supply of family doctors (3.4%) and specialists (6.4%) per
100,000 people. Large regional variations are present
across the province in the supply of healthcare providers.
t 5IFSFIBTCFFOBOJODSFBTFJOUIFTVQQMZPGOVSTF
practitioners, but there is still only one nurse practitioner
for every eight family physicians in Ontario.
t "SFXFVTJOHBUFBNBQQSPBDIJOPVSQSBDUJDF *GOPUXIBUBSF
the reasons for not using one?
t $PVMEPVSDVSSFOUQSBDUJDFCFNPSFFGmDJFOUBOEPSFGGFDUJWF
(e.g., do we have good communication and are we using
everyone’s role to its full potential)?
t 8IBUBSFUIFSPMFTBOESFTQPOTJCJMJUJFTPGUIFWBSJPVTIFBMUI
professionals? How can using other professionals reduce the
workload in our practice?
8. Populationbased health
(see chapter
9)
Smoking has seen a major decrease, but there has been little
change in other health behaviours. There is still major room to
improve population screening for preventable diseases.
t %PXFBTLPVSQBUJFOUTBCPVUUIFJSTNPLJOHDFTTBUJPOBU
each visit? Do we have a list of all smoking cessation supports
in our community for our patients? Have we considered ways
to improve access to smoking cessation programs and make it
easier for people to use nicotine replacement therapies?
t %PXFIBWFPVUSFBDIQSPHSBNTGPSQFPQMFJOIJHISJTLHSPVQT Have we made sure they know how to access them?
t %PXFVTFnPXTIFFUTUPSFNJOEVTPGBMMUIFIFBMUIQSFWFOUJPO
interventions that need to be done during periodic health exams?
t *GXFIBWFBO&.3EPFTJUHFOFSBUFSFNJOEFSTXIFOQFPQMFBSF
due for their next health prevention service?
t "SFXFPGGFSJOHQBUJFOUTTDSFFOJOHQSPDFEVSFTQFSGPSNFE
by either a male or female provider, depending on patient
preference, as well as culturally sensitive screening programs?
t $BOXFQSPWJEFBDDFTTUPWBDDJOBUJPOTPVUTJEFQSJNBSZ
care offices?
t 4NPLJOHSBUFTIBWFEFDSFBTFECZPWFSUIFQBTUFJHIU
years. However, one in five Ontarians aged 12 and over still
smoke, and rates are highest among those with low income
and education and in rural areas. Also, about one in eight
pregnant women still smoke.
t PG0OUBSJBOTBSFPCFTFIBMGUIFQPQVMBUJPOEPFTOPU
get enough physical activity, and more than half do not eat
enough fruits and vegetables.
t .PSFUIBOPOFJOGPVSTFOJPSTEJEOPUSFDFJWFBnVTIPU
About one-third of women aged 50 to 69 did not have a
mammogram in the past two years. Nearly one in four
adult women did not have a pap test in the last three years.
About one in five elderly women did not get screened for
osteoporosis.
t 0OMZBCPVUPOFJOUISFFQFPQMFBHFEUPXFSFTDSFFOFE
for colorectal cancer with a fecal occult blood test in 2009,
but this indicator is improving quickly.
13
1. Introduction and summaries
1.6
1.2
Home
summary
Accesscare
to Primary
Care
HOME CARE: summary for home and community care leaders, staff and clients
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
Topic area
Key facts
Questions to consider
1. LTC wait
times/ALC
(see section
2.4 and 6.2)
t %FTQJUFBNBKPSJODSFBTFJOUIFOVNCFSPG-5$CFETTFWFSBM
years ago, wait times to get into an LTC home are still too
high. The median wait time is 3.5 months (103 days), which
is nearly three times higher than in the spring of 2005. For
those waiting in the community, the wait is over five months;
for those waiting in hospital, it is just under two months.
The latter contributes to the serious problem of ALC beds in
hospitals — approximately one in six hospital beds in Ontario
are filled with people who could best be cared
for elsewhere.
t *OUIFQBTUZFBSUIFOVNCFSPGQFPQMFQMBDFEJOUP-5$
from hospital dropped by 19%, while the number placed
from home rose by 15%. This could be because many
communities are adopting a “Home First” approach, where
hospital patients who might have been referred straight to
LTC in the past are instead offered additional home care
services to help them return home and allow them to make
their decision about future LTC placement at home.
t 0WFSPOFJOmWFQFPQMFQMBDFEJO-5$IPNFTEPOPUIBWF
high or very high care needs. These people could potentially
be cared for in other settings in the community (e.g., with
more home care or in supportive housing arrangements).
t *TIPNFDBSFJOWPMWFEFBSMZEVSJOHUIFIPTQJUBMTUBZGPS
vulnerable clients?
t 8IBUBEEJUJPOBMIPNFDBSFTFSWJDFTBSFOFFEFEUPLFFQQFPQMF
out of LTC?
t 8IBUBMUFSOBUJWFTUP-5$OFFEUPCFDPOTJEFSFEGPSUIPTFXIP
do not need the full range of LTC services? More home care
services? Assisted living or supportive housing options?
t "SFDMJFOUTBOEDBSFHJWFSTBXBSFPGBMMUIFPQUJPOTBOETFSWJDFT
available to them?
t "SFEFDJTJPOTUPBQQMZGPS-5$QMBDFNFOUCFJOHNBEF
prematurely for hospital patients, before they have had
a chance to recover?
t 8IBUBSFUIFDIBSBDUFSJTUJDTPGQFPQMFXIPBSFUIFNPTUEJGmDVMU
to place into a LTC home, and do more specialized services in
LTC homes need to be developed for such individuals?
2. Falls
(see section
4.6)
t 0OFJOGPVSIPNFDBSFDMJFOUTSFQPSUGBMMJOHJOUIFMBTU
days. There has been no major improvement in the past
three years.
t %PXFEPSPVUJOFTBGFUZBTTFTTNFOUT "SFXFDIFDLJOHGPS
clutter or poor lighting in the home? Are there safety bars?
t "SFXFFODPVSBHJOHUIFVTFPGNPCJMJUZBJETFHXBMLFST
BOE
checking for proper use?
t "SFXFDPOEVDUJOHSJTLBTTFTTNFOUGPSGBMMTBOEJEFOUJGZJOHUIPTF
clients at highest risk of falling?
t %PIJHISJTLDMJFOUTSFDFJWFSFIBCJMJUBUJPOUPJNQSPWFTUSFOHUIBOE
balance?
t "SFBOZDMJFOUTPOBESVHXJUITJEFFGGFDUTUIBUNJHIUDBVTFB
fall? If so, have we discussed safer alternatives with the doctor?
3. Pressure
ulcers
(see section
4.6)
t "NPOHMPOHTUBZIPNFDBSFDMJFOUTIBWFEFWFMPQFE
a new pressure ulcer (stages 2 to 4) identified over the
previous six months. There has been no improvement in
the past three years.
t %PWVMOFSBCMFDMJFOUTHFUSJTLBTTFTTNFOUTGPSVMDFST "SF
they up to date? Are staff regularly monitoring for early signs
of ulcers? Are high-risk clients getting special padding to avoid
ulcers on pressure points?
t "SFIPNFDBSFXPSLFSTXFMMUSBJOFEJOJEFOUJGZJOHDMJFOUTBUSJTL
for pressure ulcers and aware of appropriate prevention and
treatment strategies?
4. Injuries
(see section
4.6)
t "CPVUPOFJOIPNFDBSFDMJFOUTSFQPSUVOFYQMBJOFE
injuries assessed over the past 90 days.
t "SFXFDIFDLJOHGPSTBGFUZIB[BSETJOUIFIPNFFHIPUXBUFS
temperature, electrical outlets and clutter)?
5. Bladder
incontinence
(see section
3.5)
t )BMGPGMPOHTUBZIPNFDBSFDMJFOUTIBWFIBEBEFDSFBTF
in bladder function, or no improvement of a past bladder
control problem since their previous assessment.
t "SFUIFSFIPNFDBSFTUBGGXIPDBOUFBDIiQSPNQUFEWPJEJOHw
protocols or bladder strengthening exercises to clients and their
informal care providers to prevent deteriorating bladder control?
t "SFDMJFOUTBEWJTFEUPTUPQDFSUBJOGPPETFHDBGGFJOF
14
1.6 Home care summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Topic area
Key facts
Questions to consider
6. Activities of
daily living
(see section
3.5)
t $MPTFUPIBMGPGMPOHTUBZIPNFDBSFDMJFOUTFYQFSJFODFEB
new problem with activities of daily living or have an old
problem that is not getting better.
t "SFIPNFDBSFDMJFOUTCFJOHPGGFSFEQIZTJPUIFSBQZPS
rehabilitation services to keep them mobile?
7. Mental health
(see section
3.5)
t "NPOHBMMIPNFDBSFDMJFOUTPOFJOFYIJCJUBTBENPPE
and at least two depressive symptoms. There has been no
improvement in the last three years.
t *TIPNFDBSFNBLJOHBSSBOHFNFOUTGPSTPDJBMBDUJWJUJFTPS
coordinating treatment of depression with the family doctor?
8. Pain control
(see section
3.5)
t "MNPTUPOFRVBSUFSPGIPNFDBSFDMJFOUTFYQFSJFODJOHQBJO
are not having their pain appropriately managed. This
indicator has not improved in the last three years.
t "SFIPNFDBSFDMJFOUTHFUUJOHGSFRVFOUBTTFTTNFOUTPGQBJO
t "SFIPNFDBSFXPSLFSTDPNNVOJDBUJOHJOGPSNBUJPOBCPVUQBJO
to the doctor so treatment plans can be adjusted?
9. Readmissions
(see section
3.3)
t "CPVUPOFJOmWFQBUJFOUTXJUIDPOHFTUJWFIFBSUGBJMVSFPS
COPD are readmitted within a month, for any cause. There
is huge room to improve these rates.
t 3FBENJTTJPOTPWFSUIFQBTUTFWFOZFBSTIBWFEFDSFBTFECZ
almost half for heart attack, which is good news.
t "SFXFNBLJOHTVSFDMJFOUTBUIJHISJTLGPSSFBENJTTJPOBSF
seen at home right after discharge?
t "SFXFNBLJOHTVSFDMJFOUTMFBWFIPTQJUBMPOUIFSJHIU
medications and know what warning signs to look out for and
who to call for help?
t "SFXFTDSFFOJOHBOENPOJUPSJOHIJHISJTLDMJFOUTXIPBSFBUSJTL
of readmission?
t "SFDMJFOUTHFUUJOHUIFSJHIUNPOJUPSJOHBUIPNFFHEBJMZ
weight checks for congestive heart failure)?
t %PXFIBWFBQSPDFTTUPFOTVSFNFEJDBUJPOSFWJFXTBSFEPOF
routinely (e.g., MedsCheck)?
t %PXFIBWFTUBOEBSEEJTDIBSHFGPMMPXVQQSPUPDPMT t "SFXFQSPNPUJOHDMJFOUTFMGNBOBHFNFOU
15
1. Introduction and summaries
1.7
1.2
Long-term
care summary
Access to Primary
Care
LONG-TERM CARE: summary for LTC leaders, staff, residents and family members
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
Topic area
Key facts
Questions to consider
1. LTC wait
times
(see section
2.4)
t %FTQJUFBNBKPSJODSFBTFJOUIFOVNCFSPG-5$CFETTFWFSBM
years ago, wait times to get into an LTC home are still too
high. The median wait time is 3.5 months (103 days), which
is nearly three times higher than in the spring of 2005. For
those waiting in the community, the wait is over five months;
for those waiting in hospital, it is just under two months. This
contributes to the problem of ALC beds in hospitals.
t 0OMZGPVSJOQFPQMFXBJUJOHGPS-5$QMBDFNFOUHFUUIFJS
first choice when placed for the first time.
t 0WFSPOFJOmWFQFPQMFQMBDFEJO-5$IPNFTEPOPUIBWF
high or very high care needs. These people could potentially
be cared for in other settings in the community (e.g., with
more home care or in supportive housing arrangements).
t 8IBUBMUFSOBUJWFTUP-5$OFFEUPCFDPOTJEFSFEPSEFWFMPQFEGPS
those who do not need the full range of LTC services? More home
care services? Assisted living or supportive housing options?
t "SFUIFSFCPUUMFOFDLTUIBUEFMBZUIFBENJTTJPOPGSFTJEFOUTUPB
home? How can the admission intake process be redesigned to
make it more efficient?
t "SFUIFSFDFSUBJO-5$IPNFTXJUIMPOHXBJUJOHMJTUTUIBU
are frequent first choices because they serve a particular
cultural, ethnic or linguistic group, or because they specialize
in handling particular types of illnesses? If so, can we redeploy
LTC resources in our region to better serve these groups?
2. Falls
(see section
4.5)
Falls are common and have changed little in recent years:
t 0OFJOTFWFO-5$SFTJEFOUTIBWFGBMMFOJOUIFQBTUNPOUI
t 5IFSFIBTCFFOOPNBKPSDIBOHFJOUIFSBUFPGFNFSHFODZ
department visits or hospitalizations as a result of falls.
There are about 3 hospitalizations for falls per 100 residents
each year.
t "SFXFFWBMVBUJOHUIFDBVTFPGFBDIGBMM "SFXFEPJOHSJTL
assessments for falls consistently? Are they up to date?
t "SFXFDIFDLJOHGPSDMVUUFSQPPSMJHIUJOHPSPUIFSIB[BSET "SF
we avoiding physical restraints, which can cause falls?
t "SFXFPGGFSJOHBOEFODPVSBHJOHUIFVTFPGBTTJTUJWFEFWJDFT
(e.g., walkers), hip protectors for those at high risk and exercise
programs to maintain strength and balance?
t "SFXFBWPJEJOHESVHTUIBUNBLFSFTJEFOUTEJ[[ZPSDPOGVTFE
(see 6 below)? If a resident is on such drugs, have we considered
safer alternatives?
t "SFSFTJEFOUTHFUUJOHQSPNQUIFMQXIFOUIFZXBOUUPHPUP
the washroom?
3. Pressure
ulcers
(see section
4.5)
t 0OFJOSFTJEFOUTEFWFMPQBOFXTFSJPVTQSFTTVSFVMDFS
over a period of three months; that’s about one in nine
residents each year. Ontario can strive to achieve a value
closer to zero.
t "SFXFEPJOHSJTLTDPSJOHGPSVMDFSTDPOTJTUFOUMZGPSBMMSFTJEFOUT t %PXFQSPWJEFUSBJOJOHGPSBMMTUBGGJOQSPUPDPMTGPSQSFWFOUJPO
(e.g., early detection, turning immobile residents regularly
and proper techniques to avoid tearing the skin when moving
a resident)?
t %PXFIBWFQSPQFSQBEEJOHPSTQFDJBMNBUUSFTTFTGPSIJHISJTL
residents?
t %PXFIBWFTUBOEBSEQSPUPDPMTBHSFFEUPCZBMMEPDUPSTGPS
treating pressure ulcers?
4. Bladder
incontinence
(see section
3.4)
t PGSFTJEFOUTmOEUIBUUIFJSCMBEEFSDPOUSPMIBTHPUUFO
worse over the past three months.
t "SFSFTJEFOUTHFUUJOHIFMQXJUIFJUIFSFYFSDJTFTUPTUSFOHUIFO
bladder muscles or learning “prompted voiding” protocols that
can help avoid incontinence?
t "SFSFTJEFOUTHFUUJOHQSPNQUIFMQXIFOUIFZXBOUUPHPUP
the washroom?
t %PSFTJEFOUTLOPXUIBUTPNFGPPEJUFNTFHESJOLTXJUI
caffeine) can worsen incontinence?
5. Avoidable
emergency
department
visits
(see section
6.3)
t 1PUFOUJBMMZBWPJEBCMFFNFSHFODZEFQBSUNFOUWJTJUTBSF
common among LTC residents. There has been no major
change in the past seven years in this area.
t 0WFSUIFQBTUTFWFOZFBSTUIFSFIBTCFFODPOUJOVPVT
improvement in the rate of low acuity emergency department
visits by LTC residents. This is good news, but there is still
be room to improve.
t 8IBUUSBJOJOHPSTVQQPSUEPTUBGGOFFEUPJODSFBTFUIFJSTLJMMTJO
handling minor emergencies without needing to transfer to the
emergency department?
t )BWFXFDPOTJEFSFEVTJOHOVSTFQSBDUJUJPOFSTUFMFNFEJDJOF
or better organized call schedules for physicians to improve
the availability of people to assess minor emergencies within
the home?
t "SFGBNJMZNFNCFSTBXBSFPGUIFQPUFOUJBMSJTLTPG
emergency department visits (e.g., confusion and
hospital-acquired infections)?
16
1.7 Long-term care summary
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Topic area
Key facts
Questions to consider
6. Drug safety
(see section
4.4)
t 5IFVTFPGESVHTUIBUTIPVMECFBWPJEFEJOUIFFMEFSMZJT
gradually decreasing. However, about one in five LTC
residents is still prescribed these drugs.
t 4IPSUMZBGUFSFOUFSJOHBO-5$IPNFPOFJOTJYSFTJEFOUTBSF
given an antipsychotic drug that they were not receiving
before (i.e., the LTC home physician — not the previous
family doctor — started the drug). One in four are given
a new drug for anxiety or sleep. There has been no major
change in the past three years. These drugs have many
risks should be avoided where possible.
t 8IZBSFQFPQMFTUBSUFEPOTMFFQJOHQJMMTPODFUIFZFOUFSBO
LTC home? What non-drug options are being tried to reduce
insomnia (e.g., avoiding caffeine, reducing noise, adopting a
regular sleep routine, avoiding long naps and managing
underlying depression)?
t "SFQIZTJDJBOTBOETUBGGGBNJMJBSXJUIESVHTUPBWPJEJOUIF
elderly? Should some drugs be removed from the formulary?
t %PFTBQIBSNBDJTUEPSFHVMBSEFUBJMFESFWJFXTPGNFEJDBUJPOT
with the involvement of family and staff?
t )BWFXFUSJFEOPOESVHBQQSPBDIFTGPSCFIBWJPVSBMJTTVFTTVDI
as aggression (see 8 below)?
t %PXFIBWFBO&)3UPCFUUFSUSBDLNFEJDBUJPOBOEQSFWFOU
adverse drug events?
7. Restraint use
(see section
4.5)
t "MNPTUPOFJOTJY-5$SFTJEFOUTXFSFQIZTJDBMMZSFTUSBJOFEJO
the previous three months. Many LTC homes are adopting
zero-restraint policies, and some countries have rates lower
than Ontario’s.
t "SFXFFEVDBUJOHTUBGGBOEGBNJMZNFNCFSTXIPBTLGPS
restraints about their hazards (e.g., falls, pressure ulcers
and asphyxiation)?
t 'PSQFPQMFXIPXBOEFSIBWFXFDPOTJEFSFEBMUFSOBUJWFTUP
restraints, such as bed and door alarms?
8. Behavioural
issues
(see section
4.5)
t PG-5$SFTJEFOUTXFSFOPUFEUPIBWFXPSTFOJOH
behaviour (e.g., aggression or wandering) in the past
three months.
t "SFTUBGGUSBJOFEJODPNNVOJDBUJPOBOEDPOnJDUEFFTDBMBUJPO
techniques to avoid making residents frustrated (e.g., good eye
contact and one-sentence questions)?
t $BOXFDPNNVOJDBUFJOUIFWBSJPVTMBOHVBHFTPGPVSSFTJEFOUT
t )BWFTUBGGDPOTJEFSFEJGUIJTCFIBWJPVSJTEVFUPBOFYJTUJOHPS
new health problem, discomfort or fear? When causes of
disruptive behaviour are identified, are solutions incorporated into
care plans?
17
1. Introduction and summaries
1.8
1.2
Cardiovascular
disease
Access to Primary
Care summary
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
Overall, there has been great improvement in the management of cardiovascular
disease, but there are still areas where Ontario can do better — particularly
with congestive heart failure.
1. Wait times for cardiovascular surgeries are within target for most
patients, but there is still room to improve. For coronary artery bypass,
angiography and percutaneous coronary intervention, the vast majority of
patients have their procedure within the target time. There is room to
improve for semi-urgent angiographies (70% completed within the target
time) and semi-urgent percutaneous coronary interventions (79% completed
within the target time).
2. More patients are on the right medications after a heart attack
but, again, there is room to improve. Use of statins, beta-blockers and
ACEIs/ARBs are at 87%, 79% and 79%, respectively, but experts suggest
these rates should be closer to 90%.
3. Heart attack incidence, mortality and readmissions are
declining. Over the last seven years, there has been a 66% reduction
in hospitalizations for angina, with a 13% decrease in the last year.
4. Congestive heart failure is still associated with high mortality
and readmissions rates. Over one-third of patients admitted with
congestive heart failure for the first time die within the following year,
and this indicator has not improved over the last six years. About 22%
congestive heart failure patients are readmitted within 30 days, and this
has not improved recently.
5. Mortality has improved for stroke but there are opportunities to do
better. Stroke mortality rates are declining and almost all patients are on
acetylsalicylic acid or other anti-thrombotic drugs, as guidelines suggest.
However, only 13% of stroke patients arriving in an emergency department
get within one hour a clot-busting drug that can reduce disability from
stroke. Also, only 29% of stroke patients get in-hospital rehabilitation to
help them regain their function, while experts suggest this figure should
be closer to 40%.
6. There have been great reductions in smoking, but progress on
other unhealthy behaviours related to heart disease has stalled.
Smoking rates have decreased from 25% in 2001 to 19% in 2009.
However, currently 18% of Ontarians are obese and half are physically
inactive, and these rates have changed little.
7. Those with low incomes and poor education continue to be at
greatest risk for unhealthy behaviours. The poorest Ontarians are
36% more likely to experience a heart attack than the richest Ontarians.
Ontarians with low incomes or poor education are twice as likely to smoke
as people with higher incomes or a better education.
18
Questions for healthcare leaders and staff to consider:
t )PXXFMMBSFSFDPNNFOEFEQSBDUJDFTCFJOHGPMMPXFE "SFQSJNBSZDBSF
providers using tools like flowsheets for heart failure or coronary artery
disease to monitor if the right drugs and tests are being done? Can
electronic medical records flag which patients are due for follow-up or
require closer surveillance because they have problems managing their
condition well?
t "SFIPTQJUBMTVTJOHUPPMTMJLFTUBOEBSEJ[FEPSEFSTBUBENJTTJPOPSDIFDLMJTUT
at discharge to ensure patients are getting all the recommended drugs and
tests? Are individual providers getting feedback on how well they are
following recommended practices?
t "SFQBUJFOUTFOHBHFEJOUIFJSDBSF )BWFXFWFSJmFEUIFZVOEFSTUBOE
the information given to them? Are they encouraged to make their own
decisions regarding their care? Are they regularly monitoring key measures,
like blood pressure or weight (for heart failure)? Do they have an action
plan that tells them what to do or who to call if they get worse?
t $BOXFUBSHFUJOUFSWFOUJPOTGPSSFEVDJOHVOIFBMUIZCFIBWJPVSTUPXBSET
those with the most to gain?
Key questions for patients with heart disease to ask themselves or discuss
with their healthcare provider:
t "N*POBMMUIFSJHIUNFEJDBUJPOT "TLBCPVUBDFUZMTBMJDZMJDBDJE"TQJSJO
B
cholesterol-lowering drug (e.g., a statin), an ACEI/ARB and a beta-blocker
for past heart attacks, blocked arteries and congestive heart failure.
t "N*HFUUJOHBMMUIFSJHIUNPOJUPSJOH 5IJTJODMVEFTCMPPEQSFTTVSFDIFDLT
periodic cholesterol tests and, for congestive heart failure patients, an
echocardiogram and daily weight monitoring.
t %P*LOPXUIFFBSMZTJHOTPGBTUSPLFTVDIBTXFBLOFTTOVNCOFTTJOBCJMJUZ
speak or write, double vision) so I know when to go to the hospital immediately?
t %P*LOPXNZUBSHFUTGPSCMPPEQSFTTVSFBOEDIPMFTUFSPM 5ZQJDBMCMPPE
pressure targets are 140/90, or 130/80 for those who also have diabetes;
the target for LDL (“bad cholesterol”) is two or less.
t 8IBUBN*EPJOHUPFMJNJOBUFTNPLJOHJNQSPWFNZQIZTJDBMBDUJWJUZBOE
achieve or maintain my ideal weight? What personal goals would I like to
set for myself? What help do I need — e.g., nutrition counselling, exercise
groups, smoking cessation aids and support from friends or family?
1.9 Diabetes summary
HOSPITAL
1.9
Diabetes summary
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Overall, there are cautious signs of improvement in managing diabetes,
but there is still a lot of room to do better — particularly in monitoring and
screening patients’ conditions and risk factors and filling prescriptions. If
Ontario is to see further progress, it will also be important for patients to be
engaged in managing their own care and setting their own targets and plans
for improving their lifestyle choices.
1. The incidence of serious complications and hospitalizations from
diabetes has decreased in the last five years, but there is still room
for improvement. Slightly more than one in 25 diabetes patients will
experience a major complication (death, heart attack, stroke, amputation
or kidney failure) in a year.
2. More patients are on the right medications for diabetes, but Ontario
is still far from ideal. Only 60% regularly fill their prescriptions for a
cholesterol-lowering drug (e.g., a statin), 67% for an ACEI/ARB, and 48%
for both. Experts suggest that most elderly diabetes patients should be
on these drugs.
3. Monitoring diabetes conditions is poor. Although all diabetes patients
should get regular eye exams, only about half do.
4. Smoking has decreased sharply in the past decade, but progress
on other unhealthy behaviours that lead to or worsen diabetes has
stalled. Currently 19% of Ontarians smoke, 18% are obese and half are
physically inactive.
5. Those with low education or income level are at greatest risk of
unhealthy behaviours that lead to or worsen diabetes. Smoking and
physical inactivity is worse among those with low income or education.
Obesity is worse among those with low education.
Key questions for healthcare leaders and staff to consider:
t "SFXFVTJOHNFUIPETTVDIBTEJBCFUFTnPXTIFFUTUPSFNJOEVTPGBMMUIF
best practices?
t *GXFIBWFBO&.3EPFTJUQSPWJEFVTXJUIEBUBPOUIFQFSDFOUBHFPGPVS
diabetes patients who are on the right drugs (e.g., a statin and ACEI/ARB)
or who have had a recent A1C test or eye exam? Have we set up the EMR
so that it reminds us when diabetes patients need testing or follow-up?
t )BWFPVSQBUJFOUTJEFOUJmFEHPBMTGPSJNQSPWJOHUIFJSIFBMUI )BWFUIFZ
been connected with a chronic disease self-management program?
t %PXFVTFBNPOPmMBNFOUJOUIFPGmDFUPEPQSPQFSEJBCFUFTGPPUFYBNT
t 8IBUBSFXFEPJOHUPSFBDIPVUUPUIFNPTUWVMOFSBCMFQPQVMBUJPOTUP
ensure they are getting services targeted to their education level, culture
or language?
Key questions for patients with diabetes to ask themselves or discuss with
their healthcare provider:
t "N*POBMMUIFSJHIUNFEJDBUJPOT "TLBCPVUBTUBUJO"$&*"3#BOE
acetylsalicylic acid (aspirin), in addition to medications to control
blood sugar.
t "N*HFUUJOHBMMUIFSJHIUNPOJUPSJOH 5IJTJODMVEFTFZFDIFDLTGPPUFYBNT
and urine tests, as well as regular blood tests for cholesterol and A1C (a
three-month average of blood sugar).
t "N*EPJOHNZPXONPOJUPSJOHPGCMPPETVHBSBOECMPPEQSFTTVSF %P*
keep a log of my measurements at home?
t )BWF*TFUUBSHFUTGPSCMPPETVHBSCMPPEQSFTTVSFJEFBMMZ
BOE
weight with my doctor?
t "N*FBUJOHQSPQFSMZBOETUBZJOHQIZTJDBMMZBDUJWF 8IBUQFSTPOBMHPBMTEP*
want to set for improving my health? What support do I need to achieve my
goals — e.g., nutrition counselling, exercise groups, smoking cessation
aids and support from friends or family?
19
1. Introduction and summaries
1.10
1.2
Cancer to
summary
Access
Primary Care
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
There has been a steady decline in death rates from some major cancers in
Ontario, likely due to better treatments and decreased smoking. However, wait
times for urgent cancer surgery and systemic treatments (chemotherapy) need
to be shortened, and more progress is needed in reducing unhealthy
behaviours and improving cancer screening.
1. Rates of lung cancer and mortality from breast cancer have
improved over the last 10 years. This is good news and may be due
to reduced smoking in previous decades and better treatments over time.
2. Wait times for cancer care can be improved, especially for urgent
cancer surgeries and systemic treatments (e.g., chemotherapy).
Only 67% of urgent (priority 2) patients have their surgery within the
recommended timeframe. Some hospitals, including North York General
Hospital, have achieved 100% through well-designed and efficient
scheduling processes. Other hospitals could do the same. Wait times for
radiation therapy have improved, with nearly four in five patients treated
within the target timeframe, but there is still room to do better. Nearly
two-thirds of patients needing systemic treatments are seen by a specialist
within the 14-day target. After being seen by the specialist, only about half
of the patients get treatment within the target timeframe.
3. Screening rates for breast and cervical cancer can still improve.
Approximately one-third of the women who need a mammogram, and
one-quarter of women who need a Pap test still do not get them. Screening
rates for colon cancer are increasing but, at 35%, are still too low.
4. Smoking has improved significantly, but progress in reducing other
unhealthy behaviours, such as inadequate consumption of fruits
and vegetables, obesity, physical inactivity and heavy drinking,
has stalled recently. At present, the rates of these behaviours in the
population are 19%, 56%, 18%, 49% and 22%, respectively. These
unhealthy behaviours have been linked to breast, colon, lung, liver,
kidney and other cancers.
5. People with low incomes and poor education levels continue to
be at greatest risk for unhealthy behaviours and for not receiving
preventive screening. For example, smoking rates are 35% for those
without a high school diploma and 15% for those with post-secondary
education. Rates for mammography screening are 59% among low-income
women, compared to 71% for those with higher incomes. Future plans to
battle cancer need to consider strategies that target the most vulnerable
in the population.
20
Key questions for healthcare leaders and staff to consider:
t 8IBUUBSHFUTBSFXFTFUUJOHGPSXBJUUJNFT *GTPNFQMBDFTIBWFBDIJFWFE
major improvements (e.g., North York General Hospital), why can we not
do the same thing?
t )BWFXFNBQQFEPVUUIFQSPDFTTFTJOWPMWFEJOBSSBOHJOHDBODFSTVSHFSZ
radiation or chemotherapy? Where are the areas of waste, duplication, error
or missed hand-offs? What are we doing to make our processes more
timely and reliable?
t %PXFIBWFJOGPSNBUJPOTZTUFNTUPFOTVSFUIBUFWFSZPOFEVFGPSDBODFS
screening is reminded?
t 8IBUBSFXFEPJOHUPSFBDIPVUUPUIFNPTUWVMOFSBCMFQPQVMBUJPOT
Key questions for people to ask themselves or discuss with their
healthcare provider:
t 8IJDITDSFFOJOHUFTUTEP*OFFEGPSNZBHFBOEHFOEFSBOEIPXPGUFO When am I due for each of these?
t 8IBUBN*EPJOHUPFMJNJOBUFTNPLJOHCFDPNFNPSFQIZTJDBMMZBDUJWFBOE
achieve or maintain my ideal weight? What personal goals would I like to
set for myself? What help do I need — e.g., nutrition counselling, exercise
groups, smoking cessation aids and support from friends or family?
1.11 Mental health summary
HOSPITAL
1.11
Mental health summary
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Suicide, depression and poor handoffs of care remain important areas of
concern in mental health. The description of mental health for Ontarians,
however, is seriously limited because there are huge gaps in the health
care system’s ability to measure the quality of services provided.
1. The rate of intentional self-harm presenting in emergency
departments has dropped in recent years, but suicide rates
remain constant. There is still room for improvement. At present,
there are 88 emergency department visits for intentional self-harm per
100,000 people. Women and in those in lower income brackets are at
greatest risk. In 2007, 1,000 people in Ontario committed suicide. There
has been no change in the past seven years. The tracking of suicide is
poor, and there is concern that suicides may be underreported.
2. Many people with mental health problems do not get primary care
follow-up after they are discharged from hospital. Almost four in 10
patients discharged from hospital after treatment for a mental illness do not
have a primary care physician visit within 30 days, and this has not
improved in the last three years.
3. Depression is a significant problem among frail or elderly
individuals. Among people receiving home care, 9.2% show serious
signs of depression, such as profound sadness or withdrawal from
normal activities. Currently, 26% of those living in LTC showed increasing
symptoms of depression or anxiety in the preceding three months.
4. Inappropriate behaviour, such as aggression, agitation or
wandering, is common among LTC residents. Since their last
assessment (three months ago), 14% of residents exhibited worsening
behaviour. These behaviours are particularly common among those with
Alzheimer’s or other dementias.
5. Many people entering a LTC home for the first time are placed on
an anti-psychotic or anti-anxiety drug that they weren’t on before.
One in six residents are given a new antipsychotic drug, and one in four are
given a new drug for anxiety (often used as sleeping pills). These drugs
have many risks should be avoided where possible.
Key questions for healthcare leaders and staff to consider:
t %PXFTDSFFOGPSXBSOJOHTJHOTPGEFQSFTTJPO t "SFXFPWFSQSFTDSJCJOHBOUJQTZDIPUJDBOEBOUJBOYJFUZESVHT "SFXFVTJOH
non-drug methods to deal with agitation, insomnia or anxiety? Are we
offering people in home care or LTC social activities or counselling? To
avoid frustration among LTC residents, are we using strategies such as
one-sentence communication, maintaining good eye contact and conflict
de-escalation techniques?
t "SFXFFOTVSJOHSFHVMBSNFEJDBUJPOSFWJFXTCZBQIBSNBDJTUXJUIJOQVU
from the client/resident, the family and staff?
t *GXFIBWFBO&.3EPFTJUNPOJUPSESVHVUJMJ[BUJPOQBUUFSOT t 8IBUBSFXFEPJOHUPSFBDIPVUUPUIFNPTUWVMOFSBCMFQPQVMBUJPOTUP
ensure they are getting the counselling they need to reduce the incidence
of self-harm? Are we making sure the services we provide take into account
people’s culture, financial and family situation?
Key questions for family members of patients experiencing symptoms of
mental illness to ask themselves or discuss with their healthcare provider:
t *TNZGBNJMZNFNCFSTIPXJOHTJHOTPGEFQSFTTJPO 8IBUJTCFJOHEPOF
to treat these symptoms? If my family member is in LTC, is there anything
in the surroundings that could be contributing? What could be done to
improve participation in activities or social networks?
t 'PSQFPQMFXIPIBWFKVTUCFFOEJTDIBSHFEGSPNIPTQJUBMGPSBNFOUBMIFBMUI
problem, has follow-up been arranged with a family doctor and other mental
health services?
t *TNZGBNJMZNFNCFSCFJOHHJWFOBOUJQTZDIPUJDPSBOUJBOYJFUZIZQOPUJD
drugs or sleeping pills (such as Valium or Ativan)? Have I discussed with his
or her doctor if these medications are necessary and if there are alternative
methods to deal with agitation, sleeplessness or anxiety?
21
1. Introduction and summaries
1.12
1.2
Data advocacy
Access
to Primary Care
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
HQO has an ongoing commitment to report on the performance of Ontario’s publicly funded healthcare system. To fulfill that commitment, the organization needs
access to up-to-date, high-quality data on the delivery and impact of the full range of healthcare services provided to Ontarians. Ontario already has some of the
best data in Canada, collected by a range of different organizations. However, there are still gaps; in some cases, the data exist but are inaccurate or impossible
to access, while in other cases, there are no data at all.
HQO believes it is important to advocate for improved data. Better data means improved reporting, and improved reporting is essential to better care. This
year, HQO has worked with stakeholders and experts to identify the questions about quality that we cannot answer without better data, why the questions are
important, and ideas on how data can be obtained.
Topic
The questions Ontario needs
to answer
Why this is important
Ideas on how to get data
Chronic
disease
management
- Are best practices being followed?
Are patients getting the right drugs,
monitoring?
- Is chronic disease well controlled?
Are physical measures (e.g. blood
pressure, weight) in a desirable range?
Chronic diseases affect a large number
of Ontarians. Billions of dollars are being
spent on treatment, yet we do not know
if we are doing a good job.
A Diabetes Registry is in progress which will
soon fill some of these gaps. EMRs in primary
care could be used to extract this data for other
conditions in the future.
Appropriateness of
services
- Are people receiving unnecessary
tests, surgeries or other procedures?
Sustainability of the health care system
depends on being able to reduce
expenditures for unnecessary care while
preserving dollars for when it’s needed.
Collect data on at least a sample of services
about whether appropriateness criteria were
met. Consider developing electronic order entry
systems where this data could be entered.
Mental health
outcomes and
access
- Do people feel any better or function
in society any better after receiving
mental health services?
- Are people getting access to the
services they need?
There are thousands of mental
health service providers in Ontario,
but little information about the impact
of their programs.
A mental health service user experience
survey could be used to measure outcomes
and access.
Patient reported outcomes
- Do people function better after
treatment or surgery? Has their
ability to move, see, hear, function
normally or live pain-free improved?
Ontario has spent billions of dollars in
reducing wait times for surgeries, but we
do not know whether or not people are
truly better off.
Consider patient surveys after receiving a
procedure. Consider adding questions to
existing surveys.
Drug utilization
and safety
- What drugs are people on?
- How frequently is harm from avoidable
adverse events from drugs occurring?
Data on drug use is needed to track if
people with certain conditions are on
the right drug; currently, this is available
only for people aged 65 and over or on
social assistance. There is very little
data on drug errors (e.g. wrong dose,
wrong drug, wrong site) and the level
of harm caused.
Ontario could learn from Alberta and
Saskatchewan*, which already have data
systems to track all drugs and allergies for
all persons.
Ontario has invested heavily in measuring
hospital-acquired infections, but relatively
little attention has been paid to
measuring other serious patient safety
issues in hospital.
Consider enhancing the existing process where
chart abstractors code data into the Discharge
Abstract Database, or using “trigger tools”
where physicians and nurses review charts that
are flagged as being anomalous (e.g. length of
stay for a condition unusually long).
Hospital
safety —
broader
measures
- What is the overall probability of being
harmed during a hospital stay?
- How frequently do these events occur:
missed diagnoses, surgical
complications, “never events” (e.g.
wrong-site surgery), death from sepsis,
or avoidable harm during a transfer
between small and large hospitals?
* Alberta’s Pharmacy Information Network and Saskatchewan’s Pharmacy Information Program offer this functionality.
†
These data are reported to the Institute for Safe Medication Practices — Canada.
22
Ontario currently has a database where
hospitals report drug errors and harm
voluntarily†; this process could be expanded
and made mandatory.
1.12 Data advocacy
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Topic
The questions Ontario needs
to answer
Why this is important
Ideas on how to get data
Health equity
- What is the gap in outcomes or
access to services between different
groups in society?
Information is available on income,
education, ethnicity and immigration
status on national survey data, but not on
other data sources. This limits the ability
to monitor societal inequalities. Also,
Ontario’s databases currently do not
identify First Nations status.
Consider adding more questions on income
or ethnicity on other surveys. Consider data
linkages with federal government data on
“Registered Indian” status. Consider ways of
adding this data to chronic disease registries
as they are developed.
Cost of
services
- How much does a health care service
cost? Who can provide a service at the
highest quality and lowest cost?
It is important to identify which models
of care achieve the best outcomes at
lowest cost, so that others can achieve
the same. Currently, there is very little
data on costs per services.
Ontario has limited experience with “casecosting” in hospitals that could either be
expanded or leveraged to other sectors.
Patient
experience
(beyond
hospitals)
- Do people who use the health
care services feel the system is
designed around their needs? How
good is communication, courtesy,
involvement in decisions, or
responsiveness to concerns?
Patient-centredness is a core attribute
of quality. It is measured routinely in
hospitals but not in other sectors. The
Excellent Care for All Act will eventually
make patient surveying mandatory
across the system.
Surveys are already in development for home
care and long-term care. Consider patient /
user experience surveys in primary care and
mental health.
Accurate
reporting
of mortality
- What is the infant mortality rate?
Suicide rate? Mortality rate for other
conditions? These are currently
tracked, but there are concerns
about accuracy.
Experts are concerned that infant
deaths are undercounted due to failure
to complete forms. Suicide may be
underestimated because information
on cause of death may only become
available after the original death
certificate is complete.
Consider re-designing the process used to track
deaths or determining cause of death.
23
2. Accessible
2.1
Wait times in emergency departments
People want to be seen quickly and cared for promptly and efficiently when they visit an emergency department (ED). After the initial
assessment, care in the ED may involve diagnostic tests, observation and/or treatment. Sicker patients need to be seen more quickly and
typically have to spend longer in the ED receiving the care they require. Care in the ED ends when the patient is either admitted to hospital
or sent home. However, patients who do not get seen quickly may decide to leave the ED. MOHLTC recently invested in a new information
system that allows it to track care in the ED. This system is an important part of the strategy to reduce ED wait times.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
People seen quickly and treated
promptly and efficiently in EDs.
Long ED wait times are inconvenient and, in some cases, negatively affect
a patient’s health.1 Spending a long time in the waiting room, or on hallway
stretchers waiting for admission, can also compromise comfort and privacy.
Ontario’s one in five residents
who visit an ED at least once
a year. 2, 3
Indicator
Value
Time trends & comparisons
th
16
12 h*
4.3 h
Hours
90 percentile wait
time for ED patients:
High complexity†
Low complexity ††
Bottom line
8
TARGET
TARGET
0
Apr 08
4.7%**
One in every 20 Ontarians who visit the ED leave without
being seen by a physician, likely because they were tired of
waiting.5 This indicator has improved over the last two years,
probably because wait times have decreased. There is still
room to do better.
10
Percent
Percentage
of patients who
left without
being seen
Sep 10
The maximum time nine in 10 patients spend in an ED
decreased in the last two years by two hours for high
complexity patients (from 14 to 12 hours), and by half an
hour for low complexity patients (from 4.8 to 4.3 hours).
Policies, investments and quality improvement activities
likely contributed to this decrease (see page 26). However,
there is room to improve, as the targets for high and low
complexity patients are 8 and 4 hours respectively.4
5
BETTER
0
Apr – Jun 08
Jan – Mar 10
2.1.4 Percentage of patients who left without being seen
100
BETTER
81%***
Percent
Percentage of
ED care completed
within recommended
time:
Overall
50
0
Apr – Jun 10
Apr – Jun 08
Admitted
patients‡
Non-admitted
high complexity
patients†‡
Non-admitted
low complexity
patients†† ‡‡
41%§
BETTER
§
90%
85%§
0
50
100
Percent
Data sources:
* National Ambulatory Care Reporting System Database (NACRS), September 2010, provided by MOHLTC.
** NACRS, January to March 2010, provided by MOHLTC
***Emergency Department Reporting System (EDRS), April to June 2010, provided by Cancer Care Ontario (CCO).
§
EDRS, FY 2009/10, provided by CCO.
†
Includes patients classified as triage level 1 (resuscitation), 2 (emergent), or 3 (urgent).
††
Includes patients classified as 4 (semi-urgent) or 5 (not urgent).
‡
Target eight hours.
‡‡
Target four hours.
24
Over the past two years, the percentage of people who were
treated in the ED within the recommended time frame has
increased modestly from 78% to 81%. While this improvement is encouraging, more than half of those patients who
are admitted to hospital are still spending more time in the
ED than is desirable. There is room for improvement.
2.1 Wait times in emergency departments
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Value
Median time
to physician
assessment
1.2 h**
Time trends & comparisons
Bottom line
2
Hours
Indicator
1
BETTER
0
Apr – Jun 08
3.4 h**
5.0
Hours
Median time from
admission to transfer
to bed
Apr – Jun 10
2.5
BETTER
People are waiting too long to see a doctor in the ED,
according to national guidelines6. The median time from
when a patient is registered in the ED to when they see
a doctor is 1.2 hours, and this has not changed over the
past two years. The current wait time is 18 minutes worse
than what it was in 2004 (see last year’s report7). There is
obvious room for improvement.
Half of patients waited more than three hours for a bed after
being admitted to hospital from the ED. There has been no
improvement in the past two years. This is consistent with the
above finding that it is the admitted patients who are least
likely to get their ED care within the recommended time.
Future efforts need to focus on this group.
0
Apr – Jun 08
NETHERLANDS
SWITZERLAND
GERMANY
US
NORWAY
UK
AUSTRALIA
SWEDEN
FRANCE
0
ONTARIO
50
NEW ZEALAND
100
CANADA
50%§§
Percent
Percentage of
Ontarians who
visited the ED and
waited two hours
or more for treatment
after arrival
Jan – Mar 10
BETTER
Half of Ontarians who visited the ED said they waited two
hours or more for treatment after arrival.††† Compared to
10 other countries surveyed, Canada and Ontario are doing
poorly. Thus, although the recent reductions in time spent
in the ED described above are welcome, Ontario is still far
from where it needs to be.
Data sources:
** NACRS, January to March 2010, provided by MOHLTC
§§
Commonwealth Fund International Survey of Adults, 2010.
†††
This indicator measures ‘treatment’, which typically occurs after the physician assessment which has a mean wait time of 1.2 hours.
25
2. Accessible
2.1
Root Cause
Ideas for Improvement
Inefficient processes for discharging patients. Patients are
occupying beds in the ED when
they should have been discharged
(e.g., to home, home care, longterm care).8
Develop better care coordination and move patients to the right place as soon as possible so they are
not occupying beds unnecessarily.
Backlogs elsewhere in the
hospital prevent patients admitted
in the ED from being sent to a bed
on the ward in a timely manner.9,10
One study found a 10% increase in
hospital occupancy was associated
with an 18-minute increase in ED
length of stay.11
Inefficiencies within the ED,
such as staffing shift change handoffs, accessing equipment and
supplies, or delays in the admission
process, which can slow processes.
t Provide alternatives for alternative level of care (ALC) patients (see section 6.2).
t Start discharge planning early and request home care assessments at appropriate times to avoid delays.
t Use bed tracking systems to reduce the time between when a patient leaves a bed and when a new patient
can use it.12
t Smooth the inflow and outflow of admitted patients. For example, Monday admissions tend to stay longer,
as do people discharged on Mondays. When admissions outnumber discharges in one day, ED waits are longer
the following day.13 Better discharge planning and more even access to certain services throughout the week
could smooth out flow.
t Spread elective surgery cases more evenly throughout the week.14 This allows for more flexibility to
accept surgical cases from the ED as they arise.
Make specific process improvements within the ED,15, 16 such as:
t Create a fast-track area for less serious cases.
t Create special units for patients who need to be under observation for several hours.
t Make simple changes in location of supplies and equipment in the ED, and use consistent locations
for common supplies to minimize wasted staff time walking back and forth.
t Use process management software to analyze data and processes to reduce non-productive work and
improve use of resources.17
t Use flexible staff scheduling. Work with staff to create arrangements where staff can be brought in for a
sudden surge in visits or stay at home when it’s quiet.18
Many hospitals have already begun adopting these ideas; future progress may depend on ensuring these ideas are
used more consistently in the province.
26
2.1 Wait times in emergency departments
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Avoidable demand from
non-urgent cases,19 which
could be addressed in settings
other than the ED.
Divert non-urgent cases away from the ED to other alternatives:20
See section 6.3 for more
on avoidable emergency
department visits.
t Improve access to after-hours primary care.21, 22
t Encourage people to call Telehealth Ontario for advice on whether an ED visit is needed.
t Implement targeted programs for specific health conditions that do not necessarily require hospital admission.
t Create “urgent care” clinics that have instant access to imaging and labs, where lower acuity patients can be
seen. For example, Alberta implemented five urgent care centres that reduced ED use by 22% to 25% during their
hours of operation.23
t Divert patients to the most appropriate service for their condition. For example, North York General
Hospital developed a successful program that diverts mental health patients from the ED to more appropriate,
community-based care services. More than half of patients who were referred to the Emergency Department
Diversion Program may have been admitted to an in-patient bed if the program’s services had not been available.24
Avoidable demand due to poorly
controlled conditions that could
have been addressed in primary
care before they escalated to
emergency care.
Improve primary care services. Improve access to primary care (see section 2.2), including after-hours
primary care and management of chronic diseases (see section 3.2), so patients are less likely to require
emergency care.
What is Ontario doing?
t *O0OUBSJPBOOPVODFENJMMJPOJOGVOEJOHUPSFEVDF&%XBJUTCZBEEJOHNPSFIPNFDBSFTVQQPSUEFEJDBUFEOVSTFTUPDBSFGPSQBUJFOUT
who arrive at EDs by ambulance to ease ambulance offload delays; and nurse-led outreach teams to provide care in long-term care homes and
avoid transfers to ED.25,26 Other announcements have committed to adding 27 physician assistants in EDs27 and 90 ED nursing positions.28
t 5
IF&%1BZ'PS3FTVMUT1SPHSBNQSPWJEFTJODFOUJWFTUPIPTQJUBMTXJUIIJHI&%WPMVNFTBOEMPOHXBJUUJNFTUPSFEVDFMFOHUIPGTUBZ*UIBTIFMQFE
participating hospitals lower overall wait times by 4.7 hours (28%) for patients requiring complex medical care or hospital admission, and by 1.4
IPVST
GPSQBUJFOUTXJUINJOPSDPOEJUJPOT"GVSUIFSNJMMJPOJOWFTUNFOUXJMMFYQBOEUIFQSPHSBNUPNPSFIPTQJUBMTGPSBUPUBMPG29
t 5
IF&%1SPDFTT*NQSPWFNFOU1SPHSBN&%1*1
IBTQSPWJEFEIPTQJUBMTXJUIPOTJUFDPBDIJOHTVQQPSURVBMJUZJNQSPWFNFOUUSBJOJOHBOEPUIFS
resources on how to lower wait times and improve patient experience. The program will support 90 hospitals by FY 2011/12.30
27
2. Accessible
2.2
Access to primary care
All Ontarians should have a regular primary care provider — preferably one who works in a team of different professionals. The primary
care provider knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive health
services and coordinates referrals to specialists. It’s important that individuals can get primary care appointments quickly when needed.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
All Ontarians have a regular primary
care provider — a family doctor or
nurse practitioner — and no one has
to wait long to see him or her.
Patients who do not get care when they need it may wait and get sicker —
or they may resort to an emergency department31 or different provider who is
unfamiliar with their medical history. Both waiting and/or seeing an unfamiliar
provider can negatively affect patients’ health32 and waste time and resources.
Ontario’s 13 million residents.
Infants see a primary care provider
for follow-up soon after birth.
Without follow-up after birth, certain illnesses could be missed and the risk of
infant morbidity and mortality increases.33
Ontario’s 136,000 babies born
every year, and their families.34
6.5%*
6
3.3%
BETTER
0
Oct – Dec 06
Jan – Mar 09
48%**
ONTARIO
6
ATLANTIC PROVINCES
12
WESTERN PROVINCES
AND TERRITORIES
CANADA WITHOUT ONTARIO
3.9%**
0
BETTER
100
BETTER
Percent
Percentage of adults
who were able to see
their doctor on the
same or next day the
last time they were
sick or needed
medical attention
Bottom line
12
QUEBEC
Percentage of Ontario
adults who do not have
a regular doctor or
other primary care
provider† to help
manage their care
Time trends & comparisons
Percent
Percentage of adults
who are:
Without a
regular doctor
Without a regular
doctor and
actively
seeking one
Value
Percent
Indicator
50
0
Jan – Mar 06
Jan – Mar 10
100
Over the past three years, the percentage of adults
without a family doctor has dropped from 8.2% to 6.5%.
About half of those persons without a family doctor
are actively looking for one, and that figure has also
decreased. This is a major improvement, and may be due
to efforts to increase the supply of family doctors and
nurse practitioners (NPs; see section 7.4); create family
health teams and NP-led clinics; and programs like Health
Care Connect that help people find a family doctor. 35
Based on survey data, Ontarians are more likely
than people in Quebec and Western Canada to have a
regular primary care provider, and as likely as those in
Atlantic Canada to have one. Ontario is no different from
France, Switzerland, Norway and the Netherlands —
four European countries with the best results among
11 countries surveyed (data not shown).
Fewer than half of Ontarians could see their doctor
on the same or next day when they became sick. No
changes have been seen in recent years. Compared
to other surveyed countries, Canada and Ontario have
some of the worst rates. In the UK, where there have
been intensive national campaigns to decrease these
wait times,36,37 68% can get an appointment within the
next day. In Switzerland, the figure is 91%. There is
huge room for improvement.
87%***
SWITZERLAND
NEW ZEALAND
NETHERLANDS
UK
AUSTRALIA
GERMANY
FRANCE
US
ONTARIO
100
BETTER
Percent
Percentage of
newborns who had a
follow-up appointment
with a primary care
provider within one
week of birth
SWEDEN
0
CANADA
50
NORWAY
Percent
BETTER
50
0
2005/06
In FY 2009/10, nearly nine in 10 newborns received
a follow-up appointment with their primary care provider
within one week of being born. There has been no change
in the past four years. There may still be room to improve.
2009/10
Data sources:
* Based on the Primary Care Access Survey, a quarterly phone survey of Ontario adults (aged 16 and over). Most recent results represent average data from FY 2009/10
** Based on Commonwealth Fund International Survey of Adults, 2010
***Ontario Health Insurance Plan, calculated by Institute for Clinical Evaluative Sciences, FY 2009/10.
†
This indicator includes “other primary care providers” where as the previous indicator does not. Also, each indicator uses different survey instruments.
Hence, the results for the two are different.
28
2.2 Access to primary care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Inconvenient or inefficient
patient scheduling. When wait
times are long, office staff waste
time responding to requests
to change or cancel appointments
and triaging patients by urgency.
Advanced access scheduling,38,39 is a method of scheduling appointments that aims to reduce wait times to see
a healthcare provider.40 Basic principles of queue management can bring wait times for appointments close to zero:
t Carefully track incoming requests and actual slots available.
t Match supply and demand41 in order to make more slots available to accommodate people who arrive with
urgent problems (e.g., if Mondays are busiest, schedule more slots then and put optional meetings on slower days).
t Work down the backlog. If supply and demand are matched but there is still a queue, then work extra hours
or hire extra help for a limited period of time to eliminate the queue.
t Reshape the demand42 to help ensure supply and demand are matched. Reduce unnecessary demand,
for example by eliminating unnecessary follow-up visits or handling minor issues over the phone or by email
(e.g., providing lab results, or renewing certain prescriptions).
t Establish contingency plans, to bring the queue back to zero when there is a surge in waits (for example,
after someone goes on vacation).
The Athens District Family Health Team, using these ideas, decreased the wait time for appointments from 27 days
to between zero to two days.43 For more information, see www.ohqc.ca/pdfs/access.pdf.
Use email or online scheduling systems44 to schedule or cancel appointments, as telephone lines are often
busy or the office may be closed.
Unnecessary work is done
in primary care offices.
Wasted staff time means less
time for appointments.
Improve office efficiency.45 Simple steps that save minutes or seconds of each clinic visit can add up to days or
weeks of saved time over a year. These include setting up every patient room in the same manner, organizing
patient records more effectively (see below), and using flow mapping to clarify and standardize complex processes
to identify where time can be saved.
Inefficient or inconsistent processes exist, such as wasting
time searching for information.
Have a well-functioning electronic medical record (EMR) system.46 EMRs can save time by decreasing
paperwork and making it easier to access test results or other information in real time. The EMR can also be set up
to monitor statistics on wait times or office efficiency.47
There is a lack of teamwork
and inefficient use of staff.
Doctors may be performing tasks or
procedures that could be performed
by another healthcare professional.
Better teamwork could increase
the number of patients in a primary
care practice and improve the
availability of appointments.
Establish interdisciplinary primary care teams and use all team members to the fullest.48,49 This can
help increase the number of patients served; for example, after the establishment of family health teams in
Peterborough, 17,000 without a family doctor gained access to primary care.56 Ensure roles and responsibilities
are clear for each team member.50 For example, nurses can do preventive health counselling, give immunizations
and coordinate patient care;51 nurse practitioners can diagnose, treat and monitor a wide variety of conditions;52,53
pharmacists can help manage medication use;54 and dieticians can provide nutritional counselling and promote
behaviour change.55 Office staff can check height and weight, check blood pressure with an automatic cuff and/or
ensure that data is input properly into EMRs.
Consider expanding legislated scopes of practice for capable healthcare professionals.
What is Ontario doing?
t GBNJMZIFBMUIUFBNT')5T
QSPWJEFNJMMJPO0OUBSJBOTPGXIPNEJEOUIBWFBGBNJMZEPDUPS
XJUIBDDFTTUPQSJNBSZIFBMUIDBSF
with 30 more scheduled to open in August 2011.57
t 5IF2VBMJUZ*NQSPWFNFOUBOE*OOPWBUJPO1BSUOFSTIJQ2**1
QSPWJEFTUSBJOJOHUP')5TPOIPXUPJNQMFNFOUBEWBODFEBDDFTT58
t QIZTJDJBOTDBSFEGPSNJMMJPOQBUJFOUTUISPVHIQSJNBSZIFBMUIDBSFNPEFMTJO0DUPCFSVQGSPNJO+BOVBSZ59
t 5
IF.0)-5$IBTGVOEFEOVSTFQSBDUJUJPOFSTJOQSJNBSZDBSFTFUUJOHTBOEDPNNJUUFEUPGVOEVQUPSFHJTUFSFEOVSTFTJOQIZTJDJBOQSBDUJDF
groups focusing on aging at home, end of life care, and mental health and addictions.60 By the end of 2012, MOHLTC aims to have 25 nurse
practitioner-led clinics operational, caring for more than 40,000 people.61
t /
PSUIFSOBOESVSBMDPNNVOJUJFTIBWFBDDFTTUPUIF/PSUIFSOBOE3VSBM3FDSVJUNFOUBOE3FUFOUJPO*OJUJBUJWFJODMVEJOHGSFFUVJUJPOGPSSFUVSOPG
service, outreach programs, and support for visiting physicians and health centres.62
29
2. Accessible
2.3
Treatment wait times and access to specialists
When people get sick, they may need to see a specialist, have surgery, undergo sophisticated diagnostic imaging tests and/or receive
specialized therapy. Access to these important healthcare services should be organized so that those who need them most urgently
receive them most quickly. The Ontario Wait Times Strategy,63 launched in 2004 to reduce wait times for key surgeries and diagnostic
tests, set targets to ensure that the highest priority patients get care as quickly as they need it. In addition, Cancer Care Ontario has set
target wait times for radiation and chemotherapy.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
No one has to wait a long time to see
a specialist.
Patients worried about a disturbing symptom may experience unnecessary
anxiety waiting to see a specialist for a diagnosis. They may also get sicker
while waiting, leading to a more extensive surgical procedure or a more
advanced stage of the disease.
Ontarians requiring a specialist
referral. Six people are referred
to a specialist each year for
every 10 people who have
a family doctor.64
No one has to wait longer for hip and
knee replacements than the target
wait time.
Patients will endure pain and suffering for a longer period of time.65 They may
also lose their ability to participate in activities and exercise,66 which could
worsen other conditions such as diabetes, hypertension and depression.
Ontario’s 35,000 people who
have hip or knee replacements
each year.
No one has to wait longer for cataract
surgery than the target wait time.
People will endure poor vision for a longer period of time and may experience more falls.67
Ontario’s 139,000 people
who have cataract surgeries
each year.68
No one has to wait longer for cardiac
procedures — angiography, percutaneous coronary intervention† or
coronary artery bypass graft — than
the target wait time.
Waiting too long for coronary interventions increases risk of death.69
Ontario’s 64,364 people who
have angiographies, 20,598
people who have percutaneous
coronary interventions and 8,308
people who have coronary artery
bypass grafts each year.70
No one has to wait longer for cancer
treatments — surgery, radiation or
systemic therapy (chemotherapy) —
than the target wait time.
Patients anxious about a cancer diagnosis may experience high levels of
stress waiting for treatment, which makes wait times undesirable, even if
they do not statistically affect survival.
Ontario’s more than 62,000
people who will be diagnosed
with cancer this year and
their families.71
No one has to wait longer for CT or
MRI scans than the target wait time.
If a CT or MRI scan is not carried out promptly to find cancer, surgery may
be delayed72 and patients may experience unnecessary anxiety waiting for
a diagnosis.
Ontario’s residents who receive
1.8 million CT and 570,000 MRI
scans each year.73
Procedure
Priority 1*
(immediate)
Priority 2*
(high urgency)
Priority 3*
(medium urgency)
Priority 4*
(low urgency)
MRI/CT scan
Immediate
2 days
10 days
4 weeks
Cataract surgery
Immediate
6 weeks
12 weeks
26 weeks
Hip and knee replacements
Immediate
6 weeks
12 weeks
26 weeks
Cancer surgery
Immediate
2 weeks
4 weeks
12 weeks
General surgery
Immediate
2–4 weeks
12 weeks
26 weeks
Cardiac procedures (coronary
artery bypass graft, angiography,
percutaneous coronary intervention†)
Wait time targets are specific to each patient.
Cancer — radiation therapy
From 1 to 14 days depending on the patient’s condition.
Cancer — from referral to consultation with specialist for chemotherapy
14 days
Cancer — from consultation with
specialist to start of chemotherapy
14 days
Data sources:
* MOHLTC, Ontario Wait Times Strategy, provided by Cancer Care Ontario and Cardiac Care Network. Note that the wait for surgery is defined as starting the day the surgeon decides to
operate and the patient agrees, and ending the day the surgery is performed. Target wait times vary depending on the priority score, indicating the seriousness of the conditions, assigned
by the main physician.
†
Also known as balloon angioplasty, where a catheter with a balloon is threaded into the artery of the heart to open blockages. Usually, a stent is inserted to keep it open.
30
2.3 Treatment wait times and access to specialists
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Time trends & comparisons
51%*
Bottom line
GERMANY
SWITZERLAND
US
UK
NETHERLANDS
SWEDEN
AUSTRALIA
FRANCE
0
NORWAY
ONTARIO
50
NEW ZEALAND
100
CANADA
Percentage of people
who report waiting
four weeks or more
for an appointment
after they were
advised to see or
decided to see a
specialist doctor
(or consultant)
Value
Percent
Indicator —
specialist
wait times
BETTER
Half of Ontarians report waiting four weeks or more for
an appointment to see a specialist doctor (or consultant).
Compared to 10 other countries surveyed, Canada and
Ontario have the worst standing on achieving timely
access to specialist doctor/consultant care. There is
major room for improvement.
Data sources:
* Based on Commonwealth Fund International Survey of Physician Practices, 2010
Value
90th percentile wait
time for cancer
surgeries
51
days*
Time trends & comparisons
BETTER
50
0
Aug-Sept 05
67%*
78%
93%
IDEAL
50
0
Jan 08
84%**
Dec 10
100
BETTER
Percent
Percentage of patients
where radiation
therapy started within
target (from being
ready to treat
to getting treatment)
The maximum amount of time nine in 10 people will wait
for cancer surgery is just under two months. Wait times
decreased from 2005 to 2008, but there have been no
further improvements in the past two years. There is still
room for improvement.
Dec 10
100
Percent
Percentage of cancer
surgeries done
within target:
Priority 2
Priority 3
Priority 4
Bottom line
100
Days
Indicator —
cancer wait times
50
One-third of urgent (priority 2) cancer surgery patients
are not getting their surgery within the recommended
two weeks. This is still a major problem to be addressed.
The results for priority 2 do appear to have improved in
the last year, but it is possible that much of this apparent
improvement may have been due to changes in coding
practices. The number of cases coded priority 2 have
dropped by 40%, while priority 3 and 4 cases have
increased by 17% and 25%, respectively.
More than eight in 10 patients receive radiation therapy
within the targeted time. This has improved in the past
two years, but opportunities to improve further need to
be explored.
0
Apr 09
100
BETTER
61%**
47%
Percent
Percentage of
systemic treatment
(chemotherapy) completed within target:
Referral to
consult
Consult to
treatment
Dec 10
50
0
Apr 09
Dec 10
Nearly two-thirds of patients needing systemic treatment
are seen by a specialist within the 14-day target. This
indicator has improved in the last two years. After being
seen by the specialist, almost half of the patients receive
treatment within 14 days. This component of a patient`s
wait, however, has not improved. There is still significant
room for improvement.
Data sources:
* Cancer Care Ontario and Wait Times Information System; data values represent data for December 2010.
** Cancer Care Ontario; data values represent data for December 2010.
31
2. Accessible
2.3
90th percentile wait
time for:
CT scans
MRI scans
Value
Time trends & comparisons
Bottom line
150
29
days*
113
days
BETTER
Days
Indicator —
CT/MRI
wait times
75
0
Aug-Sept 05
The maximum amount of time nine in 10 people
wait for a CT scan is about one month. This is a
remarkable improvement; back in 2005, the wait
was almost three months.
Wait times for MRI, however, remain stuck at around
four months, the same level seen in 2005. Wait times
did decrease in 2008 but have since rebounded upwards
to their previous level.
Dec 10
The number of CT scans has almost doubled in the last
seven years, while the number of MRI scans has almost
tripled.74 These increases in volume appear to have
helped reduce waits for CT, but not for MRI.
Clearly, there is room for improvement, particularly
for MRI wait times.
100
90%*
64%
81%
Percent
Percentage of CT
scans done within
target:
Priority 2
Priority 3
Priority 4
IDEAL
50
0
Jan 08
100
75%*
51%
30%
Percent
Percentage of MRI
scans done within
target:
Priority 2
Priority 3
Priority 4
Dec 10
IDEAL
50
0
Jan 08
Dec 10
Data sources:
*Cancer Care Ontario and Wait Times Information System; data values represent data for December 2010.
32
Over the past three years, the percentage of CT scans
done within the target time has improved at all priority
levels. High priority patients are the most likely to have
their CT scan done within the target time, which is
reassuring. While the improvement is encouraging,
there is still room to do better.
Over the past three years, MRI waits have improved for
urgent priority (2) cases but gotten worse for low priority
(4) cases. At present, three-quarters of urgent priority
patients received an MRI within the target time frame,
but only 30% of priority 4 patients did so. There is major
room for improvement.
2.3 Treatment wait times and access to specialists
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Percutaneous
coronary
intervention
Percentage of
coronary artery
bypass grafts done
within target:
Urgent
Semi-urgent
Elective
Percentage of
angiographies done
within target:
Urgent
Semi-urgent
Elective
Time trends & comparisons
The 90th percentile wait times for each of these cardiac
procedures have remained fairly constant over the past
three years. There are peaks in wait times around January
and August, coinciding with post-holiday periods.
Days
33
days*
25
BETTER
17
days
15
days
0
Oct 08
Nov 10
100
86%*
94%
99%
IDEAL
50
Oct 08
Nov 10
100
85%*
70%
98%
IDEAL
50
Almost all elective and 85% of urgent angiographies are
completed within the recommended timeframe. There has
been improvement from the previous year for semi-urgent
cases; however, there is room to do better.
0
Percent
100
85%*
79%
98%
Almost all elective and semi-urgent coronary artery
bypass grafts are done within the target time. There is
some room for improvement for urgent cases as
the rate is 86%.
0
Oct 08
Percentage of
percutaneous
coronary
interventions done
within target:
Urgent
Semi-urgent
Elective
Bottom line
50
Percent
90th percentile wait
times for:
Coronary
artery bypass
graft
Angiography
Value
Percent
Indicator —
cardiac
wait times
Nov 10
IDEAL
50
0
Oct 08
Nov 10
For elective percutaneous coronary intervention, the results
look good as the rate of cases done within target continues
to be close to 100%. Performance for urgent cases, however
has declined. Two years ago, 99% were done within the
target time; the current figure is 85%. For semi-urgent
cases, there are on-going challenges as the current result
(79%) has not improved in the last two years. There is room
for improvement.
Data sources:
* Cardiac Care Network, November 2010. Note that some patients move between urgency categories.
33
2. Accessible
2.3
Other indicators
Value
Time trends & comparisons
90th percentile
waits for:
Bottom line
500
206
days*
Knee
replacement
200
days
Cataract
surgery
122
days
General surgery
97 days
BETTER
Days
Hip
replacement
250
One cautionary note is that these wait times were at their
lowest point in 2009 and in 2010 they increased slightly
by about two weeks; in the future, it will be important to
monitor these results carefully to ensure that Ontario holds
the gains it made in the last few years.
0
Aug-Sept 05
The maximum amount of time nine in 10 people wait for
hip or knee replacement is just under seven months, and
for cataracts, four months. This represents a remarkable
improvement as waits are less than half of what they were
in 2005. These improvements result from the province’s
Wait Times Strategy63 which provided incentives to do
these procedures, created an information system to track
wait times, and offered coaching teams to help hospitals
do these procedures more efficiently.
Dec 10
General surgery wait times have been tracked only in
the past three years, and have been steady at just over
three months.
Percentage of cases
done within target
General surgery:
Priority 2
83%*
Priority 3
91%
Priority 4
97%
Cataract surgery:
Percent
100
IDEAL
50
0
Apr 08
66%*
Priority 3
69%
Priority 4
96%
Percent
100
Priority 2
Dec 10
IDEAL
50
More than nine in 10 patients requiring low or medium
urgency general surgeries are served within the target
time. Wait times are generally stable. High priority
patients, who account for 6% of all surgical cases, have
more difficulty getting their surgery on time, although
their needs are the most pressing. There is room for
improvement for high priority cases.
Almost all low urgency cataract surgeries and almost
seven in 10 medium urgency cataract surgeries are
completed within the target time. These cases account for
97% of cataract surgeries. There is still room to improve
for high urgency cases.
0
Jan 08
Hip replacement:
74%*
Priority 3
66%
Priority 4
84%
Percent
100
Priority 2
Dec 10
IDEAL
50
0
Jan 08
Knee replacement:
63%*
Priority 3
63%
Priority 4
88%
Percent
100
Priority 2
Dec 10
IDEAL
50
0
Jan 08
Dec 10
Data sources:
* Cancer Care Ontario and Wait Times Information System; data values represent data for December 2010.
34
More than one-quarter of hip replacement patients and
more than one-third of knee replacement patients are
not treated within the target time. High priority patients
continue to have greater difficulty getting their surgery
completed within the recommended timeframe. Early
improvements that were seen have stalled in the past year.
There is room for improvement.
2.3 Treatment wait times and access to specialists
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
People are placed on waiting lists for
procedures they don’t need. One study found
27% of people who got cataract surgery did not get
improved vision, and may not have needed it in the
first place.75 Another study suggests 26% of CT and
MRI scans for headaches are inappropriate.76 Overuse
of CT is potentially dangerous; each CT scan emits
100 times the radiation of standard X-rays.77
Implement appropriateness criteria to ensure that patients truly require surgery or a specific
test. (See section 6.4 for more about avoiding unnecessary drugs and tests). There are objective
criteria for determining urgency for certain procedures (e.g., hip or knee replacement78,79,80,81, and
cataract surgery82,83), but no requirement to use them at this time. Provider education and tools
that provide clinical decision support would help ensure that patients receive CT scans and MRIs in
the most appropriate circumstances. MOHLTC and University Health Network in partnership with St.
Joseph’s Healthcare Hamilton have developed an online CT and MRI decision support tool for use
by providers.85
Overuse may be due to providers not following best
evidence when ordering a test or procedure, or the
patients wanting a procedure without understanding
risks and benefits.
Use priority tools. These are designed to prioritize patients on scheduled waiting lists to ensure
that those who are at greatest need receive the procedure first.86,87
People are getting a procedure for a problem
that could have been prevented with better
health habits.
Adopt strategies to improve health habits (see section 9.1). Tackle obesity, which worsens
arthritis and can lead to more hip and knee replacements.88 Reduce smoking, which can lead to
coronary artery disease and more cardiac procedures.
Queues may vary in size between different sites
that provide a service. Those who are “stuck” in a
particularly slow queue may have very high wait times.
Pool different queues into a single queue. At a typical bank, having a single line where each
person goes to the first available teller is far more efficient than having a separate line for each
teller. Based on this principle of queuing theory89, several LHINs have implemented centralized
bookings for surgical procedures, specialist appointments and diagnostic tests to reduce wait times.90,91
There is natural variation in demand and
sometimes surges in demand occur, which
can lead to a major increase in wait times.
Queue management principles suggest that to accommodate surges in demand, at least some
slack capacity is needed to keep wait times low.92 This is true for both the surgery and other
services that need to happen before and after. Complex surgeries may require the patient to stay
in the intensive care unit (ICU) afterwards. Potential solutions include innovations in surge capacity,
evening out surgical procedures and/or a surgical ICU throughput unit for short length of stay
post-operative ICU patients.
Even if the demand and supply of services
is matched, any queue that may have built up
in the past will persist and lead to people
waiting unnecessarily.
Work down the backlog.93 Temporarily increase the rate of procedures being performed until
this backlog is eliminated, and then return to the previous rate.94
There are inefficiencies in arranging surgery.
This may include delays or errors when sending
booking information or delays in arranging preoperative tests or consults.
Implement standardized processes for arranging surgery. This could include on-line booking
tools (instead of relying on paper-based referrals that can be illegible or get lost) or standard
checklists for patients and providers to ensure all steps are arranged well in advance.
Demand is greater than the available supply
of services, and in many cases is growing. In some
instances, the demand for surgery is not measured
and the capacity for the procedures is inadequate.
Measure demand for surgical services and respond accordingly. This should be done routinely
so the capacity for procedures can be adequately matched to the demand. That is, balance supply and
demand.95 Careful monitoring of incoming demand, projections of future demand, and careful planning
of the number of procedures needed now and in future years will help to ensure the demand is met.96
Consider all possible ways to introduce efficiencies before adding additional capacity.
What is Ontario doing?
t .
0)-5$DPNNJUUFENJMMJPOUPXBSETDBQJUBMQSPKFDUDPTUTBOENJMMJPOUPXBSETBOOVBMGVOEJOHGPSUIF4USPOBDI3FHJPOBM$BODFS$FOUSF
It is expected to provide radiation treatment to more than 2,400 patients annually.97 It currently delivers 7,500 chemotherapy treatments annually,
a number expected to increase by 10% to 15% annually until 2013. By 2012, it should accommodate 100,000 outpatient visits annually.98
t 5ISPVHIUIF8BJU5JNFT8FCTJUF0OUBSJBOTIBWFBDDFTTUPUIFNPTUDPNQSFIFOTJWFTVSHJDBMXBJUUJNFJOGPSNBUJPOJO$BOBEB99
t 5
IF.3*1SPDFTT*NQSPWFNFOU1SPHSBNIBTQSPWJEFEIPTQJUBMTXJUIPOTJUFDPBDIJOHBOEUSBJOJOHUPJNQSPWFFGmDJFODZBOEBDDFTTUP
diagnostic imaging and lower MRI wait times. It will support all Ontario hospitals with an MRI scanner by FY 2011/2012.100
t 5
IF1FSJ0QFSBUJWF$PBDIJOH1SPHSBNIBTQSPWJEFEIPTQJUBMTXJUIPOTJUFBOESFNPUFQFFSDPBDIJOHUPJNQSPWFUIFFGmDJFODZBOERVBMJUZPG
pre- and post-operative care and reduce surgery wait times.101
35
2. Accessible
2.4
Access to long-term care and home care
A central role of home care is to help people who have difficulty caring for themselves continue to live independently. In Ontario, community
care access centres (CCACs) arrange services such as nursing, personal support, physiotherapy, occupational therapy, speech-language
therapy, social work, nutritional counselling, medical supplies and equipment.102 When people can no longer stay at home, even with home
care, CCACs arrange placements to long-term care (LTC) homes.103 Normally, the person and/or his or her loved ones select up to three
homes, in order of preference. Once it is determined that someone needs LTC, it is vital to place them as quickly as possible or they may
not get the care they require and, if their condition deteriorates, those caring for them at home may struggle to cope.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
No one has to wait a long time to get
into an LTC home.
People waiting at home for LTC may be at risk of further decline and may
place a heavy burden on loved ones who are caring for them. People waiting in
hospital for LTC are occupying hospital beds unnecessarily, and this can lead
to overcrowding in emergency departments and wasted resources.
Ontario’s 21,500 seniors who are
on the waiting list for placement
into an LTC home each year, and
their families and caregivers. 104
As many people as possible get their
first choice of LTC home.105
When people are placed in their second or third choice for an LTC home, they
may end up further from loved ones or in a home that doesn’t specialize in
meeting their ethnic, cultural or medical needs. It is possible for LTC residents
to move to a higher-ranked choice later, but this may be inconvenient and
disrupt continuity of care.
No one has to wait a long time to get
home care services.
People waiting for home care services may experience a decline in their condition, and this may result in hospitalizations that could have been avoided.
Indicator
Value
Time trends & comparisons
Median number of
days to LTC home
placement:
Bottom line
Wait times to get into an LTC home are too high. The median
wait time is 3.5 months. The wait time for those placed
from home is over five months, and for those placed from
hospital, it is almost two months.
250
Those placed
from hospital
103
days*
56
days
Those placed
from home
161
days
Days
Overall placements
125
BETTER
0
Apr – Jun 03
LTC home placement volumes:
Apr – Jun 10
Those placed
from hospital
1,179
Those placed
from home
1,860
Number
3,348
3,500
0
Apr – Jun 03
Data sources:
* MOHLTC Long-term Care Client Profile Database, April to June 2010.
36
Wait times increased sharply between 2005/06 and 08/09.
In the most recent 12 months, however, overall wait times
have stopped increasing. This suggests that the problem
is starting to stabilize. The reasons for this remain to be
determined, but it is possible that the province’s Aging at
Home strategy (see below) may have helped stabilize waits.
However, the problem is still far from being fixed. The
current overall wait is still nearly three times higher than
in the spring of 2005.
The way people enter LTC has shifted recently. In the past
year, the number of people placed into LTC from hospital
dropped by 19%, while the number placed from home rose
by 15%.107 This could be because many communities are
adopting a “Home First” approach,108 where hospital patients
who might have in the past been referred straight to LTC are
instead offered additional home care services to help them
return home and allow them to make their decision about
future LTC placement at home.
7,000
Overall
Ontario’s more than 585,000106
home care clients who receive
services from CCACs each year.
Apr – Jun 10
The wait time for those placed from hospital has increased
by 10 days in the past year even though fewer people
were admitted to LTC from hospital, possibly because less
complex patients are better candidates for the Home First
approach, while those remaining take longer to place. The
decrease in patients being referred to LTC from hospital is
a welcome step to help address the problem of Alternative
Level of Care patients occupying beds in hospitals, but it is
important to ensure that that excessive burden is not put on
informal caregivers at home in the process.
2.4 Access to long-term care and home care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Value
Percentage of residents placed in LTC
who got their first
choice of home the
first time around
39%**
Time trends & comparisons
100
Percent
BETTER
50
0
Apr – Jun 06
Jan – Mar 10
100
Percent
Percentage of
Ontario seniors
newly receiving
nursing home care
following hospital
discharge, by time
to first nursing
service visit
0–1 days
2–3 days
4 or more days
Bottom line
50
0
Apr – Jun 05
Jan – Mar 10
Only four in 10 people waiting for LTC placement got their
first choice when placed for the first time. This has not
changed in the last four years. The province currently
encourages people waiting for LTC placement while in
hospital to take the first available choice among their top
choices.109 While this can help reduce Alternative Level of
Care bed days (see section 6.2), it makes it challenging to
improve on this indicator.
More than half of all people discharged from the hospital
who require home care services are receiving their first
nursing visit within one day. Over the past four years, no
major changes have been seen in this indicator. Nearly 20%
of post-acute patients who need home care services are
waiting more than four days for their first nursing visit. This
suggests there may be room to improve.
62%***
19%
19%
Data sources:
** MOHLTC Long-term Care Client Profile Database, FY 2009/10.
***Home Care Database , Discharge Abstract Database, Registered Persons Database, FY 2009/10.
37
2. Accessible
2.4
Root Cause
Ideas for Improvement
Issue: LTC waits and people in LTC who don’t necessarily require it
Services needed exceed what caregivers
can provide and what home care can offer.
Reasons may include:
t Family caregivers, who provide 80% of
home care for individuals with chronic
conditions110, may burn out or have health
problems themselves, and then can
no longer provide care.
t The person is socially isolated and has no
family caregivers.
t The person cannot afford to pay for extra
care (e.g. more home care or
retirement home).
t The person and/or family are not
aware of options.
t A CCAC can only provide a level of service
that its budget allows.
There were missed opportunities to prevent a
decline in health that led to admission to a LTC
home. These could include:
t Preventable falls or injuries
The following are alternatives to long-term care placement:
Respite care for family caregivers11,112 (e.g. allow placement of a person in a hospital for a limited
time to give caregivers a break).
Community support or day programs.
Extended home care hours or services. This could include nursing, rehabilitation, home making,
meals on wheels, and personal support services that include dressing, personal hygiene, assisting with
mobility, monitoring of medicine use and other routine activities of living.113
Supportive housing/assisted living arrangements. These are publicly funded or subsidized
housing options where people live in their own apartments but there are caregivers available on site
to provide more frequent services. Planners in Lethbridge, Alberta using this lower-cost model have
kept LTC waits to less than a month, while using one-third fewer LTC beds per capita than in Ontario.114
At present, there are some such arrangements in Ontario115,116, often managed by non-profit organizations. Rent subsidies are available to eligible seniors, but the criteria are stringent and waiting lists for
subsidized units can be long. 117Overall, Ontario does not have a coordinated province-wide plan for
supportive housing. This is now the third year that Quality Monitor has raised this issue.
Retirement homes can also provide some types of additional support, but are available only to those
who can afford them.
Opportunities to preserve health include:
t Falls prevention (see section 4.5).
t Better chronic disease management through better monitoring or more consistent use of the
right drugs or treatments. (see section 3.2).
t Deterioration of a chronic condition
t Promotion of a healthy lifestyle (see section 9.1).
t Poor health habits
t Rehabilitation and other services for the frail elderly to combat de-conditioning
in hospitals.118 Ontario’s Senior Friendly Hospital Strategy has tips on making the physical
environment more pleasant, increasing the use of assistive devices (e.g. canes and walkers),
improved nutrition and better communication.119
t “Deconditioning” among hospitalized
patients; being in an unfamiliar environment
like a hospital can accelerate one’s loss
of physical function.
Premature labelling of hospital patients as
needing LTC. When people go to hospital with a
sudden worsening of their condition, they may be
told to go to LTC before they have had a chance
to recover.
The “Home First” approach, as noted above, aims to return hospitalized patients to their home first
and avoid making a decision about LTC placement in the hospital. This approach gives the patient time
to recover from the worsening of his or her condition, and allows home care workers to make a better
assessment of an individual’s true level of function.
People who fear long waits may want to get
themselves on the list “just in case.” Recent
data indicates that 22% of clients placed in LTC
Homes have MaPLE scores that are not high
or very high indicating they could potentially
be placed elsewhere (see section 6.2).
Apply the MaPLE score120 to objectively determine an individual’s needs. Encourage those people
who do not have high or very high needs to consider alternatives to LTC.
38
2.4 Access to long-term care and home care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Issue: People do not get their first choice for LTC.
There are not enough LTC homes serving
specific populations.
Consider planning for more capacity, or shifting existing LTC bed capacity, to serve ethnic or
linguistic groups or communities that have particularly long waiting lists. With more options available,
individuals might have a better chance of getting their first choice.
The community lacks sufficient LTC capacity
to meet local needs. Some people may wish to
stay in a community where their family resides or
where they have support, but there may be little
LTC capacity there.
Establish regional plans for LTC. Residents should not have to move far outside their communities
to receive LTC.
Establish more specialized services — for example, programs that target individuals with complex
behavioural issues or medical complexities.121, 122
What is Ontario doing?
t 5
IFQSPWJODFT"HJOHBU)PNFTUSBUFHZ123, 124JTBNJMMJPOJOWFTUNFOUPWFSUISFFZFBSTUP
XJUIUIFBJNPGFOBCMJOH
seniors and their caregivers to live healthy, independent lives in their own homes and avoid premature admission to LTC homes. LHINs are
using this funding to provide enhanced home care and community support services, as well as fund innovative projects with their LHIN.125
t .
0)-5$JTSFCVJMEJOHFYJTUJOHCFETBOEVQEBUJOHGBDJMJUJFTBU-5$IPNFT126 This is part of a provincial plan to redevelop 35,000 older
beds over 10 years to help improve access to LTC throughout Ontario.127
t 4JODF.0)-5$IBTDSFBUFEOFX-5$CFETBOEJUXJMMCFPQFOJOHBOBEEJUJPOBM-5$CFETPWFSUIFOFYUGFXZFBST128
t *O.0)-5$BOOPVODFEUIF4USFOHUIFOJOH)PNF$BSF4FSWJDFTJO0OUBSJPTUSBUFHZXIJDIDPOTJTUTPGGPVSLFZEFMJWFSBCMFTUPTUSFOHUIFO
home care: improving accountability for the provision of quality home care services through public reporting on quality measures; delivering
improved health outcomes for Ontarians through the Integrated Client Care Project; enhancing fairness, transparency and communication in
the competitive procurement process; and promoting innovation and flexibility in service provision.129
39
3. Effective
3.1
Receiving the right treatments in hospital
People are commonly admitted to hospital following a heart attack, stroke or worsening of congestive heart failure130, and the appropriate
administration of certain medications can save lives, prevent future complications of an illness and preserve health. Meanwhile, for pregnant
women, it is important that obstetrical units provide a supportive environment for women to deliver their baby safely and effectively.
Caesarean sections should be done only when necessary.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Appropriate administration of a beta-blocker, a
statin to lower cholesterol132 and an angiotensinconverting enzyme inhibitor (ACEI)133 or angiotensinreceptor blocker (ARB)134 to people who have had a
heart attack (acute myocardial infarction — AMI).
Patients may experience more strokes, repeat heart
attacks and death.
Ontario’s 20,000 people
hospitalized for heart
attacks each year.135
Appropriate administration† of an ACEI/ARB136
and a beta-blocker137 for most people who have
congestive heart failure. Patients with the slightly more
common138 “systolic dysfunction” form of heart failure
(weak pumping action) should get these drugs; for
those with the “diastolic dysfunction” form (stiff heart
wall), these drugs should be considered.139,140
Patients may experience more hospitalizations, worse quality
of life and death.
Ontario’s 16,000 people
admitted to hospital with
congestive heart failure
each year.141
Appropriate administration† of acetylsalicylic acid
(ASA, or aspirin) or an anti-thrombotic drug (blood
thinner)142 for people who have had a stroke.
Patients may experience more repeat strokes.
Ontario’s 16,000 people
who experience a new
ischemic stroke
each year.143
Appropriate administration† of a clot-busting drug
for people who can get to a major hospital right
after symptoms of a stroke begin.144
Patients may experience more disability (e.g., loss of use of
arm or leg, or speech) and death.
An effective method of delivery for women in
labour. Caesarean sections are performed
only when necessary.
Caesarean sections may lead to higher infection rates,145 increased
respiratory distress of the newborn,146 a stay in hospital that
is twice as long, increased risk of readmission to hospital and
increased cost to the system.
†
Percentage of elderly patients
with congestive heart failure
who, within 90 days of discharge, filled a prescription for
the recommended drugs:
ACEI/ARB
Beta-blocker
Both at once
Time trends & comparisons
BETTER
87%*
79%
79%
59%
50
2009/10
100
BETTER
71%*
66%
50%
50
0
2002/03
2009/10
Over the last seven years, there has been major
improvement in the use of statins after a heart
attack (from 67% to 87%). However, there has
been little change in the use of beta-blockers and
ACEIs/ARBs.
Use of all three drugs at once has improved over
the last seven years, but the percentage has
levelled off in the last two years. There is room
for further improvement as guidelines suggest
it may be possible to increase the use of these
drugs to 90%.148
0
2002/03
Ontario’s over 135,000
women who give birth in
Ontario each year.147
Bottom line
100
Percent
Percentage of elderly patients
with AMI who, within 90 days of
discharge, filled a prescription
for the recommended drugs:
Statin
Beta-blocker
ACEI/ARB
All three at once
Value
Percent
Indicator
131
The use of beta-blockers for congestive heart
failure patients after discharge has increased over
the past seven years, while ACEI/ARB use has
decreased over the same time period. There is
probably room for improvement in the use of these
drugs, although making a definitive conclusion on
that will be possible only when Ontario has better
data on what type of heart failure patients have
(see data advocacy section, 1.12).
Data sources:
* Registered Persons Database, Discharge Abstract Database (DAD), Ontario Drug Benefits Database, FY 2009/10, calculated by Institute for Clinical Evaluative Sciences (ICES). These
indicators are calculated only for patients aged 66 and older, as data on drug use was only available for this group. The indicators track prescriptions filled. Some people might fill the
prescription but not actually take the drug; hence, the rate of actual use may be lower.
†
These drugs should be used except when contraindicated, such as allergy to the drug.
40
3.1 Receiving the right treatment in hospital
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Value
Percentage of acute stroke
patients discharged on ASA or
anti-thrombotic therapy
92%**
Time trends & comparisons
Bottom line
100
Percent
BETTER
50
0
2003/04
13%**
100
BETTER
Percent
Percentage of ischemic stroke
patients eligible for thrombolysis (clot-busting drug) who get it
within one hour of arriving in the
emergency department††
2009/10
50
0
2003/04
29***
BETTER
50
0
2005/06
Rate of low-risk# first-time mothers who deliver a full-term baby
via Caesarean section
(per 100 deliveries)
15§
Only one in eight patients who had a stroke and
could benefit from clot-busting drugs received
those drugs within one hour of arriving in the
emergency department. Although gains have
been made over the past six years, there is still
huge room for improvement.
2009/10
100
Rate
Rate of delivering via Caesarean
section (per 100 deliveries)
About nine in 10 stroke patients are receiving the
recommended blood-thinning drug when they are
discharged from hospital. This indicator has not
changed in the last four years. The typical rate
of allergies or sensitivity to these drugs149,150 is
close to the rate of people not on these drugs
(8%); hence, there is probably little if any room
for improvement.
2009/10
The Caesarean section rate in Ontario is 29%. This
has not changed in the past four years. Among
low-risk mothers, 15% of pregnancies were
delivered by Caesarean section.
The overall Caesarean section rate is higher than
the World Health Organization’s recommended
rate of 15%.151 However, the validity of this target
is disputed and there is no consensus in Canada
on what the ideal rate should be. Nonetheless,
these rates should be monitored carefully and
opportunities to avoid unnecessary Caesarean
sections should be explored.
Data sources:
** Registry of the Canadian Stroke Network, FY 2009/10, calculated by ICES. This indicator looks at ischemic stroke/transient ischemic stroke patients discharged alive from the
emergency department or an acute in-patient setting of a regional stroke centre (note that this analysis does not include hemorrhagic stroke).
*** DAD, calculated by ICES, FY 2009/10. Indicator methodology adapted from the POWER Report.152
§
Niday Perinatal Database, FY 2009/10, provided by BORN Ontario.
††
This indicator looks at ischemic stroke patients who arrive at the emergency department of a regional stroke centre within 2.5 hours of stroke symptom onset.
#
Low-risk women are those who do not have many of the common indications for a C-section. They are first time mothers and therefore could not have had a past C-section; the baby’s head
is pointing downwards; the baby is not premature; the labour was spontaneous; and it is a single pregnancy (i.e. not twins). They may still have a C-section if the labour is not progressing.
41
3. Effective
3.1
Root Cause
Ideas for Improvement
Issue: Drug management.
Healthcare providers may not order the right
drugs or treatments because of information
overload — they are busy, distracted by
other patient issues or there are too many
things to remember.
Poor communication when care is
transferred between providers could lead
to information about the right treatments not
being passed on. For example, there may be
a good reason to initially delay giving a drug
(e.g., beta-blockers for a heart attack), but
whoever is handling the care at a later point
must know that the drug should be started
when safe to do so.
Increase the availability and use of standardized admission orders, discharge checklists,
standardized care plans or algorithms to help decide when to order a drug or test.
Use clinical decision support systems to guide prescribing choices. Increase the use of electronic
health records (EHRs) that can guide clinicians’ decisions and generate clinical reminders.153 Such
systems provide recommendations on when to start, monitor, or stop treatments and can identify safety
issues (e.g. dangerous drug combinations). These systems may have a useful influence on provider
behaviour154 and patient outcomes,155 especially when they deliver timely and relevant information, suit
local needs (avoiding a “one size fits all” approach) and are accompanied by ongoing technical support.156
Providers are not aware of how closely
they are following guidelines.
Provide regular feedback to prescribers. For example, the Enhanced Feedback for Effective Cardiac
Treatment (EFFECT) publicly releases hospital performance data on indicators for AMI and congestive
heart failure treatments.157 This data should also be provided at an individual provider level.158
Patients do not fill prescriptions given to
them at discharge. This could be because they
fear the side effects, or do not understand
when, why, how to, or how long to take the
drug. Some drugs have minor side effects
that require some getting used to; if the patient
does not know that, he or she may
discontinue the drug prematurely.
Encourage hospital staff to review medications with patients prior to discharge159,160 and ensure
that patients leave hospital with printed information, including an easy-to-follow “meds list” with key
changes noted. Providers can use the “teach back” method to ensure information has been understood
by patients and caregivers.161,162 Encouraging patients to keep meds lists also keeps them engaged in
their own care.163
Medication discrepancies put patients at
risk of medication errors. This happens
when someone enters or leaves hospital, and
there is confusion about what drugs he or she
was on previously.
In one study, almost half of all patients had at least one medical error when discharged from hospital to
the community.166 Encourage primary care providers to spend time with patients reviewing drugs
after discharge167 — and ensure the provider has received hospital discharge information by the time
this visit takes place.
Follow-up by telephone and interactive voice response systems may help identify drug interactions
and encourage newly discharged patients to take medications as prescribed.164,165
Issue: Timely thrombolysis of stroke patients.
Diagnosis of stroke is delayed. This may
occur if a patient goes to a centre that does
not have the right equipment or special skills
in handling strokes.
Ensure stroke cases are sent by ambulance directly to designated stroke centres that have the
most experience in handling stroke. This resulted in faster arrival times to a stroke centre in Toronto and
a four-fold increase in getting thrombolysis to patients who need it.168 This is also a recommendation from
national stroke guidelines.169
Enhance telemedicine capabilities so that in rural hospitals, where stoke expertise may be limited, CT
scans can be reviewed by neurologists and stroke experts located elsewhere.170
Poor hand-offs or communication might
delay timeliness. One US study found major
delays between writing the order and giving the
thrombolysis drug.171
42
Create standardized processes and order sets for initiation of thrombolysis.172
Consider creating a specialized team to administer thrombolysis, as one hospital
in Calgary has done.173
3.1 Receiving the right treatment in hospital
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Issue: High Caesarean section rates.
More women may be having planned
C-sections with no medical reasons.
There is no data on how often this happens
in Ontario, but it is a growing world-wide
phenomenon.174,175 Reasons may include:
the convenience of knowing the delivery
date in advance; fear of pain; and fear of
complications of vaginal delivery (e.g.
incontinence or vaginal prolapse). Also,
a planned C-section is more convenient for
providers, allowing for predictable scheduling.
Inform the public and healthcare providers about the risks of planned C-sections. Although
overall risk of Caesarean section is small, planned Caesarean sections are associated with a three times
greater risk of severe complications (e.g., hemorrhage requiring hysterectomy, cardiac arrest, venous
thromboembolism, major infection) than planned vaginal birth,176 as well as higher healthcare costs.177
Efforts to educate can include individual discussions between patients and providers, as well as public
awareness campaigns. For example, several New Jersey hospitals have signed onto a “Worst to First”
campaign to reduce C-section rates to 15%.178 Public campaigns can also emphasize that childbirth
is a natural physiological process.179
Medicolegal concerns. Obstetricians already
have the highest malpractice insurance
premiums among specialists in Canada180.
Use of second opinions and applying objective criteria for C-sections181 were found in one study
to reduce C-sections by one-third. It is possible that these approaches could help reassure obstetricians
they are making the right decision to hold off on a C-section when they are worried about a potential
medicolegal case.
Skill of provider — physicians may not feel
comfortable with procedures that are
alternatives to C-sections, such as forceps
to rotate the baby into a better position for
delivery,182 trial of labour among women with
past C-sections183, or vaginal delivery
of breech presentations. 184
Consider augmenting training standards for obstetricians, family doctors and midwives in
training in the use of these skills, or providing more retraining opportunities for existing
practitioners who wish to sharpen these skills. Emergency drills and patient simulators allow health
care providers to practice handling difficult situations as a team (similar to flight simulators for pilots),
and their use in obstetrics could be greatly expanded.185
Unnecessary inductions. When labour
is induced, the chance of a C-section is
much higher.186
Set up protocols for appropriate induction. Doctors at a Pittsburgh hospital developed a protocol
where elective inductions could be scheduled only if the baby was at least at 39 weeks and the cervix
was “ripe” based on an objective score. Inductions were reduced by one-third and C-sections among
first-time mothers being induced decreased from 35% to 14%.187
Lack of consensus among providers that
C-section rates are a problem.
Audit and feedback mechanisms allow individual practitioners to regularly review their own data
on measures like C-section rates, complication rates and adherence to guidelines and identify areas
for improvement. 188
Rising obesity rates. Obesity is associated
with a two-fold higher rate of C-sections. 189
Consider population-based strategies to reduce obesity overall (e.g. food labelling, healthy
communities that promote physical activity, etc.; see section 9.1).
What is Ontario doing?
t The Champlain Get with the Guideline Initiative helps ensure that all patients in the Champlain LHIN who are admitted to hospital for a heart
attack or symptoms of a heart attack get the best care.190 Participating hospitals implement a discharge tool that includes care pathways,
standard orders, discharge checklists, reminders and a data collection tool that tracks whether patients are getting all of evidence-based
guidelines (e.g. the right drugs for heart attack). Hospitals also get several days of coaching time to help them use these tools correctly.
t The Ontario Mother and Infant Study is a multi-site investigation involving 2,500 Ontario women to assess the impact of planned Caesarean
vs. planned vaginal delivery on maternal and infant health, service use and the cost of care.191
43
3. Effective
3.2
Chronic disease management
Chronic diseases, which require management over a long period of time, are widespread.192 They affect one in three Ontarians and
almost four in five Ontarians aged 45 and over. Among Ontarians with a chronic disease, about seven in 10 have two or more chronic
conditions.193 These conditions tend to get gradually worse over time and can result in pain, suffering, disabling complications or premature
death.194 There is also a tremendous economic burden associated with chronic diseases, with the expense amounting to 55% of total direct
and indirect health costs in Ontario.195 Although chronic diseases cannot be completely cured, lifestyle changes, medical treatments and
careful monitoring can reduce the risk of getting them or slow their progression.196 This year’s report focuses on diabetes, heart disease and
lung diseases. Future reports will aim to include other conditions.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Regular monitoring for people
with chronic diseases (e.g., regular
eye and foot exams for patients
with diabetes).197
The consequences of not having regular eye and foot exams may include
more blindness,198 skin ulcers199 and amputations.200
Ontario’s 937,000 people with
diabetes,201 over 18,000 people
who experienced a heart attack
last year, and almost 16,000
people admitted to hospital
with congestive heart failure
each year.202
Healthy lifestyles for people with
chronic diseases (e.g. avoidance of
smoking, obesity, poor diet, physical
inactivity and heavy drinking).203
Unhealthy behaviours can lead to worsening of chronic diseases and speed
up the development of long-term complications or other conditions. 204,205
People with chronic conditions should
be taking the right medications and
feel confident about how to manage
their own conditions.
For diabetes, the consequences may be more deaths and more complications, such as strokes, heart attacks, amputations and other surgeries for
poor circulation, kidney failure and dialysis.206,207,208,209 Other consequences
may include avoidable hospitalizations and emergency department visits,
which are stressful for patients and waste healthcare resources.210
Monitoring and management of chronic diseases
Indicator
Value
Percentage of people with
diabetes who had an eye exam
in the past 12 months
51%*
Time trends & comparisons
Bottom line
100
Percent
BETTER
50
0
2002/03
Percentage of elderly people
with diabetes (aged 66+) who,
in the past year, regularly filled
prescriptions for:
ACEI/ARB††
Statin
Both at once
56%
25%
19%
2009/10
80
Percent
18%**
57%
40
BETTER
0
2001
2009
100
BETTER
Percent
Unhealthy habits of people with
chronic diseases†:
Heavy drinking
Low fruit/vegetable
consumption
Physical inactivity
Obesity
Smoking
67%***
60%
48%
50
0
2003/04
Approximately half of people with diabetes
received an eye exam in the past 12 months.
This rate has been generally steady over the past
8 years. There is huge room for improvement;
nearly all patients with diabetes should get
this test regularly.
2009/10
Smoking rates have improved significantly
among people with chronic diseases in the past
nine years. Rates of physical inactivity and
inadequate fruit/vegetable intake have improved
slightly, but heavy drinking and obesity have
been on the rise. All of these self-reported rates
are still too high, and there is still major room for
improvement as healthy behaviours are critical
for this population.
Over time, Ontario has seen slow but steady
improvement in the use of ACEIs/ARBs and
statins among people with diabetes. However,
there is still room to improve, since only half
of elderly people with diabetes are getting
both of these drugs and experts suggest
most elderly people with diabetes should
be receiving them.211,212,213
Data sources:
*Ontario Diabetes Database (ODD), Ontario Health Insurance Plan, Registered Persons Database, FY 2009/10, calculated by Institute for Clinical Evaluative Sciences (ICES).
**Canadian Community Health Survey, 2009, calculated by ICES.
***Ontario Drug Benefits Database, ODD, FY 2009/10, calculated by ICES. This indicator tracks prescriptions filled. Some people might fill the prescription but not actually take the drug;
hence, the rate of actual use may be lower.
†
Includes high blood pressure, diabetes, arthritis, heart disease, cancer, asthma, respiratory problems and depression.
††
ACEI=angiotensin-converting enzyme inhibitor. ARB=angiotensin receptor blocker.
44
3.2 Chronic disease management
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Complications of chronic diseases
Adjusted mortality rate
(chance of death) in the
year after a congestive heart
failure hospitalization
Time trends & comparisons
Bottom line
6
4.30%*
0.15%
Percent
Percentage of people with
diabetes for more than a year
who had a serious diabetes
complication within a year:
Any serious complication
Surgery for circulation
problem (including
amputation)
Death
Heart attack
Stroke
Kidney failure
Value
2.70%
1.10%
0.51%
0.17%
3
BETTER
0
2003/04
35**
2009/10
Slightly more than one in 25 people with
diabetes will experience a major complication of
diabetes within a year. Last year, this amounted
to 40,000 people in Ontario. The rates of
these complications have decreased steadily
in Ontario, which may be due to better use of
drugs such as statins and ACEIs or decreased
smoking (as noted above), or to earlier
detection of diabetes. Despite the improvement
in complication rates, there is room for even
more improvement. As noted above, services
like eye visits are not done reliably, and recent
one-time studies in Ontario have identified
major gaps in blood pressure, blood sugar and
cholesterol control.214 Ontario does not collect
this information regularly, and needs to do so
in the future (see data advocacy section 1.12).
BETTER
Over one-third of patients admitted to hospital
for congestive heart failure die within the next
year. There has been no improvement in this
indicator over the last six years. There is likely
room to improve.
BETTER
One in 11 patients die within one year of having
a heart attack. This has improved over the
last three years. There may still be some room
to improve — for example, by further
reducing smoking rates.
50
Rate
Indicator
25
0
2002/03
9.1**
20
Rate
Adjusted rate of death per 100
heart attack patients between
30 days and one year after their
first heart attack
2008/09
10
0
2002/03
2008/09
Data sources:
*Discharge Abstract Database (DAD), Ontario Health Insurance Plan physician billings database, Registered Persons Database (RPD) and Ontario Diabetes Database (ODD), FY 2009/10,
calculated by Institute for Clinical Evaluative Sciences (ICES). Complication rates adjusted for age, sex and number of years since diagnosis of diabetes.
**DAD and RPD, FY 2008/09, calculated by ICES. Mortality rates adjusted for age and sex. Indicator methodology adapted from the POWER Report.215
45
3. Effective
3.2
Root Cause
Ideas for Improvement
It is challenging for providers to
follow best practice guidelines
100% of the time. This may be
due to:216,217,218,219
Use flow sheets in patient charts.220 Flow sheets are one-page documents with checkboxes to record compliance with best practices for each patient encounter. The Canadian Diabetes Association has a recommended
version for diabetes.221
t Information overload. It is
easy to forget to order a drug
or test, or keep track of latest
guidelines.
t Organizational barriers (e.g.
difficulty accessing information
about the patient that could
change a clinical decision)
t Scepticism about the validity
of the evidence.
Reminder systems prompt a health care provider to perform a particular action (e.g. remember when it is time to
schedule another annual eye exam), and can be paper-based or electronic.222,223
Have a well-functioning electronic medical record (EMR). EMRs often have flow sheets and reminder utilities
built into the software. Decision support features in EMRs go beyond reminders and help providers choose
among treatment options, such as drugs that are recommended in specific clinical circumstances (e.g., diabetes).224, 225 One clinical decision support system improved rates of prescription of hypertension drugs by 32%.226
Provide confidential feedback on a clinic or provider’s performance according to best practice guidelines,
to give them an idea of how they are performing and to help them identify areas for improvement.227, 228, 229
Opinion leaders can help encourage the adoption of evidence-based practices. Identified by their peers, these
“educational influentials” operate within their communities to teach and facilitate change.230, 231
For best results, simultaneously employ as many as possible of the change ideas noted above.
Multifaceted interventions are the most likely to be successful in changing provider behaviour.232
It is difficult for healthcare
providers to manage frail elderly
patients with multiple chronic
conditions. Managing these patients
well may require a more intensive
level of monitoring or more
specialized expertise.
Consider establishing specialized clinics for chronic disease(s), such as diabetes or congestive heart
failure, staffed by a multidisciplinary team. A review of heart failure treatment programs found that patients
receiving this type of care had approximately 25% reduced risk of mortality and hospitalization for heart failure.233
An anticoagulation clinic set up in Peterborough has achieved an 80% rate of patients on anticoagulation medication
in the safe dosing range (vs. 55% of patients in usual monitoring).234
Patients may not be engaged in
their own care. People may not be
motivated to change, or may not feel
as if they have the power to do so.
Promote patient self-management of behavioural risk factors and chronic disease (see section 9.1). Congestive
heart failure patients who self-monitor their weight daily can spot warning signs of worsening congestive heart
failure quickly and get their medications adjusted before they need to go to hospital.238 Improve access to health
education and health promotion activities and materials.239, 240, 241 (see section 9.1).
Employ telemedicine technology to monitor patients. Consider using “tele-homecare” to monitor and
communicate with patients,235 especially those who are house-bound or who live in remote locations.236,237
What is Ontario doing?
t The Ontario Diabetes Strategy has two public targets: ensuring that all people with diabetes have access to a primary health provider and that 80%
of people with diabetes, aged 18 and older, have all three diabetes tests (cholesterol, retinal eye exam and A1C) within recommended guidelines for
optimal diabetes management.242 As part of this strategy, MOHLTC is creating 51 new diabetes education teams, expanding chronic kidney
condition services, creating up to 14 regional coordination centres and expanding diabetes care and prevention resources.243
t Primary and specialty care providers in Peterborough have implemented a population-based care model for vascular disease called the
Comprehensive Vascular Disease Prevention and Management Initiative (CVDPMI). This initiative targets the asymptomatic “non-help-seeking” patients
and uses the electronic medical record and practice protocols to screen them for conditions like high blood pressure or high cholesterol. Those
found to be at high risk for vascular events receive dietary counselling, lifestyle management planning and medications where needed. Initial clinical
findings show that CVDPMI patients have an up to 50% reduction in cardiac event risk. 244
t MOHLTC plans to further reform the prescription drug system by reducing the cost of generic drugs by at least 50%, eliminating excessive
payments to pharmacy owners from generic drug companies, and offering patients in rural communities wider access to lower-cost drugs.245
t The Heart & Stroke Foundation recently launched an online Heart & Stroke Risk Assessment Report for self-evaluation based on a short, simple
survey that looks at risk factors for heart disease. 246 It also started the Heart & Stroke Foundation Hypertension Management Initiative and Program
helps primary care providers and patients improve hypertension control. It includes flowsheets, reminders, audit and feedback tools, automatic
blood pressure cuffs and support in implementing these ideas, which is designed to enhance the management and control of hypertension by
primary care providers, including doctors, nurses and pharmacists, and patients.247
46
3.2 Chronic disease management
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
47
3. Effective
3.3
Potentially avoidable hospitalizations
People who are frail with multiple chronic conditions require hospitalization if their condition deteriorates. Often, however, these hospitalizations
could be avoided. Ambulatory care sensitive admissions (ACSCs) is a measure which tracks admissions which took place for a condition which,
if carefully managed in a primary care setting, might have resulted in not needing to go to hospital. Another measure is readmissions, which
can occur if there is not a smooth handoff from the hospital to primary care providers or home care.248,249,250 Readmissions are tracked using
two methods: one that tracks readmissions for the same condition, and follows a national definition that allows for provincial comparisons, and
another that tracks readmissions for all causes, which is currently in more common use in Ontario.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
The best possible management of
chronic diseases, so that people are
less likely to be admitted to hospital.
Worsening of a chronic condition that could have been avoided and that
results in admission means worse quality of life, increased stress, exposure
to risks while in hospital (e.g. hospital acquired infection), increased burden
on family and wasted healthcare resources.251
The Ontarians who contributed
to the over 34,000 potentially
avoidable hospital admissions
last year.252
Effective treatment in hospital and
proper follow-up care arranged in
the community to avoid readmission.
When patients are readmitted, their health may worsen and, along with
their families, they may experience lost time and economic productivity.
In addition, unnecessary readmissions increase the cost of hospital care.253
Ontario’s residents who visit
an emergency department
or hospital.
Ambulatory care sensitive conditions
Value
Hospital admission
rate per 100,000
population for all
ambulatory care
sensitive conditions
(ACSCs)
278*
Time trends & comparisons
225
BETTER
0
2002/03
B.C.
ONTARIO
ALBERTA
QUEBEC
MANITOBA
NOVA SCOTIA
YUKON
P.E.I.
SASKATCHEWAN
NFLD./ LAB.
BETTER
84*
CHF is the second-most common ACSC. Admission rates
declined from FY 2002/03 to FY 2006/07, and better
use of certain drugs (e.g., beta-blockers) might have
contributed to this trend. There has been no change in
the last three years and there is major room to improve.
75
52*
40*
36*
32*
BETTER
0
In FY 2008/09, Ontario had the second lowest rate of
ACSCs compared to other provinces. However, there are
individual regions within the country that have even lower
rates — for example, in Richmond, B.C., the rate is 154
(almost half as low as Ontario’s rate), and the Central LHIN
rate is 183. This suggests that there is room to improve.
COPD is currently the most common ACSC. Admission
rates have not changed since FY 2002/03, and there is
major room to improve.
150
Rate
Hospital admission
rate per 100,000
population for:
Chronic obstructive pulmonary
disorder (COPD —
e.g., emphysema,
chronic bronchitis)
Congestive heart
failure (CHF)
Asthma
Angina
Diabetes
NEW BRUNSWICK
0
N.W.T.
700
In FY 2009/10, roughly 34,100 people were admitted
to hospitals in Ontario for complications from chronic
diseases that could potentially have been prevented with
good primary care. The rate has decreased by 33% over
the last seven years, and decreased by 5.2% compared to
last year. There is still room for improvement.
2009/10
1,400
NUNAVUT
**
Rate
Interprovincial
comparisons for
overall ACSCs
Bottom line
450
Rate
Indicator
2002/03
2009/10
The rate of asthma admissions improved significantly
from FY 2005/06 to FY 2007/08, but there has been
no change in the past two years. Continued improvement
is necessary.
Over the last seven years, there has been a 66%
reduction in hospitalizations for angina, with a 13%
reduction just in the last year. These improvements
could be due to reduced smoking (section 9.1), better
use of drugs like statins (section 3.1), and timely use
of revascularization procedures (e.g. bypass or stents;
section 2.3).254 This is good news, and Ontario should
continue to aim for more reductions.
Diabetes hospitalizations have decreased by 26% over
the last seven years, with much of the change seen in the
last year. Continued emphasis is necessary to sustain this
level of improvement.
Data sources:
*Discharge Abstract Database, FY 2009/10, calculated by Institute for Clinical Evaluative Sciences.
** Canadian Institute for Health Information, Health Indicators, 2010. Note that minor variations in methodologies were used to calculate overall ACSC rates when comparing time trending to
interprovincial comparisons.
48
3.3 Potentially avoidable hospitalizations
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Readmissions
Indicator
Readmissions for any reason:
Congestive heart failure (age ≥ 45)
COPD (age ≥ 45)
Gastrointestinal conditions (all ages)
Diabetes (all ages)
Cardiac conditions (age ≥ 40)
Pneumonia (all ages)
Stroke (age ≥ 45)
Value
Time trends & comparisons
Bottom line
People who have been discharged
from hospital for COPD or congestive
heart failure have the highest rates
of readmission for any cause in
Ontario — higher than those who
have been hospitalized for pneumonia
or stroke.
22%*
19%
16%
14%
12%
12%
8.2%*
BETTER
0
15
30
Rate
Readmission rates for
specific or related mental health
conditions:
Schizophrenia and bipolar disorder
Mental health and addictions
Depression
11%**
7.7%
7.8%
5.4%
4.3%
3.9%
2.6%
Rate
14
7
BETTER
0
2002/03
7
BETTER
0
2005/06
4.6%§
BETTER
Hospitals whose patients use more
evidence-based drugs for heart attack
after discharge also tend to have lower
readmission rates.
10
AMI Readmission Rate
Nearly one in 10 individuals with
schizophrenia or bipolar disorder is
readmitted within 30 days of being
discharged from hospital. This has not
improved over the past three years.
The complexity of care for psychotic
illnesses is higher than for other
conditions and non-adherence with
treatment is among the biggest risk
factors for readmission.255
Improvement is necessary.
Ontario has the second lowest rate of
readmissions for people who have been
hospitalized for an AMI. It is still behind
Alberta, suggesting there may still be
room to improve.
ALBERTA
ONTARIO
B.C.
SASKATCHEWAN
MANITOBA
NOVA SCOTIA
NEW BRUNSWICK
P.E.I.
NFLD./ LAB.
7
0
Relationship between AMI readmission
rate and percent of seniors who were
on three drugs recommended for AMI
after discharge†
2009/10
14
Rate
AMI readmission rates for specific or
related conditions across Canada
Readmissions over the past seven
years have decreased by almost half
for heart attack, which is good news.
However, there have been only very
slight improvements for COPD, CHF,
asthma, diabetes, gastrointestinal
conditions and stroke. There is huge
room for improvement.
2009/10
14
9.6%
6.3%
3.9%**
Rate
Readmission rates for a specific or
related condition:
Congestive heart failure
COPD
Gastrointestinal condition
Diabetes
AMI (heart attack)
Asthma
Stroke
5
0
<40%
40-49%
50-59%
60-69%
>70%
Percent of AMI patients (66 and over) who filled prescriptions
for three key drugs after discharge
Data sources:
*MOHLTC–LHIN Performance Agreement, FY 2009/10.
**Discharge Abstract Database (DAD) and Registered Persons Database (RPD), FY 2009/10, calculated by Institute for Clinical Evaluative Sciences (ICES). All figures represent readmission
rates to any acute care hospital within 28 days of discharge, for people aged 15 to 84, per 100 discharges.
§
DAD, FY 2008/09, Canadian Institute for Health Information, Health Indicators, 2010. †The three drugs are beta-blockers, angiotensin converting enzyme inhibitors or angiotensin
receptor blockers, and statins. Prescriptions had to be filled within 90 days after discharge. Each dot represents a group of hospitals within each category.
49
3. Effective
3.3
Root Cause
Ideas for Improvement
Patients do not get all the right
medications while in hospital.
(See scatterplot on previous page, which
shows that low use of the right drugs is
associated with higher readmissions.)
Healthcare providers may not order the
right drugs or treatments because they are
busy, distracted by other patient issues or
there are too many things to remember.
Use standardized admission orders, order sets for common clinical conditions and discharge
checklists, as well as EHRs that generate clinical reminders.257 These can help remind prescribers
to order the right drugs and coordinate integrated care after discharge. See section 3.1.
Administrators and healthcare
providers may not be aware of the
extent of the readmission problem.258
In urban communities where multiple
hospitals serve a large population base,
readmitted patients may end up at
a different hospital.
Feedback information on readmissions, or data on compliance with guidelines, should go to
hospital administrators, providers and staff.259 Ensure this data includes readmission to other
hospitals. If possible, provide this information at an individual healthcare provider level to help each
provider and unit develop their own quality improvement plans.260
Pressure to free up beds may lead
to premature discharge and
subsequent readmission.
Implement strategies to reduce avoidable demand for hospital beds. See section 2.1, 2.2 and 2.4
People are not getting the intensity
of follow-up that they require.
Do risk-scoring to identify patients at high risk for readmission, and arrange more intensive
follow-up for them. One such tool, the LACE index, takes into account the length of stay (“L”); acuity of
the admission (“A”); comorbidity (“C”); and recent emergency department use (“E”).261 High-risk patients
could be referred to more intensive follow-up such as a specialized clinic or tele-home care.
Information about the admission and
discharge plan is not quickly transferred
to the patient’s primary care provider
or to community service providers.
Failure to communicate relevant information
may adversely affect patient care.262,263
Consider database-generated discharge summaries and other strategies discussed in section 8.1 to
improve patient care during the transition from hospital to home.
Patients may not understand
instructions for their care following
discharge from hospital — how to take their
medications, what signs to look for or whom
to call if they have concerns.
Consider contacting patients by phone 48 hours after discharge to ensure the planned treatment
plan is progressing well.265 Or, have patients return to hospital for an ambulatory visit soon after discharge.
Poor coordination of transition from
hospital to home.
Use a structured discharge summary for frail elderly patients, with standardized elements which contain
information that healthcare providers in the community receiving the summary need to know to manage the
patient well. This is the approach used by one team in Quebec.264
Improve and expand the information given to patients and caregivers at discharge, incorporating
“best practice” methods of communication,266 and conduct teaching sessions that include patients and
family members post-discharge. Providing patients with written discharge instructions has been shown
to decrease readmissions, particularly for congestive heart failure.267 See section 8.1 for details on the
“teach-back” method and other communication strategies to improve patient understanding of care
and discharge instructions.
Ensure better coordination among hospital, community service and primary care settings (see section
2.4). Institute standard discharge follow-up protocols268 for frail patients, such as a home visit through
a CCAC on the patient’s first day post-hospital. To ensure a patient gets a follow-up primary care visit soon
after discharge (e.g. one week), have hospital staff request or confirm the booking of the appointment.
Keep in touch with patients. An Ottawa-based project successfully used interactive voice response
systems to monitor patients post-discharge.269 An automated telephone recording asks patients certain
questions about symptoms or use of drugs and patients enter their response. If there are worrisome
responses, a nurse follows up with a phone-call.
50
3.3 Potentially avoidable hospitalizations
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Patients with chronic conditions don’t
get the right monitoring.
Promote patient self-management (see section 9.1). Congestive heart failure (CHF) patients who
self-monitor their weight daily can spot warning signs of worsening CHF quickly and get their medications
adjusted before they need to go to hospital.270
Consider establishing dedicated clinics for chronic diseases, such as heart failure,271,272 diabetes273,274
and conditions requiring anticoagulation therapy.275 See section 3.2 for more on how to improve the
management of chronic diseases.
Patients develop infections while in
hospital that may not appear until after
the patient has gone home.
See section 4.1 for ideas on how to improve infection control.
Patients don’t get the right rehabilitation
services after discharge.
Set up appropriate home care to provide patients with rehabilitation and monitoring
of conditions.
Consider arranging a falls risk assessment through a CCAC soon after the patient has returned home.
What is Ontario doing?
t The “Virtual Ward” project, funded by MOHLTC and being piloted at several sites, improves transitions from hospital to home by combining the
best aspects of hospital, primary and home care after hospital discharge. Launched in March 2010, the project is an innovative partnership between
the Toronto Central CCAC,277 St. Michael’s Hospital and Women’s College Hospital. Toronto Central LHIN278 is also participating. The partners are
working together to create an integrated team — including an attending physician and nurse practitioner from the hospital and a care coordinator,
pharmacist and nurse practitioner from the CCAC — to support clients discharged from hospital who are at high risk for readmission. This team
meets daily to discuss the care management of clients on the virtual ward. Once clients have safely transitioned home and no longer need ongoing
follow-up, they are discharged from the virtual ward. Many clients continue to receive CCAC services.
276
t MOHLTC recently added financial incentives for primary care practices that provide comprehensive primary healthcare services to patients.
Compensation is based on blended payments linked to the number of patients enrolled and includes additional financial incentives for accepting
acute care and vulnerable complex patients who were previously without a family physician.279
51
3. Effective
3.4
Keeping people healthy in long-term care
Ontario’s LTC homes care for people who have difficulty looking after themselves. These homes can provide services that help residents
achieve and maintain their independence for as long as possible. For example, physiotherapists can teach staff in the homes exercises that
keep residents mobile, as well as providing specialized programs as needed.280 Occupational therapists can suggest devices and nursing
interventions that assist people with everyday activities,281 such as dressing and eating. In addition, pleasant surroundings and a variety of
recreational and social activities can help prevent depression.282
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
LTC residents preserve their well-being
and ability to function as long as
they can, through activities to help
preserve bladder function and physical
mobility, control pain, preserve
language, memory and thinking
abilities, and avoid depression
and weight loss.
Without bladder function and physical mobility, residents may experience loss
of independence, reduced quality of life and increased risk of pressure
ulcers. Without appropriate pain control and activities that are stimulating,
they may endure needless suffering, be unable to participate in activities
and feel social isolation. Depression and a loss of appetite can lead
to decreased energy, mood and mobility, and premature death.
Ontario’s 75,000 residents in
the over 600 LTC homes across
the province.283
Indicator
Value*
Bottom line
Percentage of residents with worsening† bladder control.
21%
Percentage of residents with increasing† difficulty carrying out normal, everyday tasks (getting dressed, eating, personal hygiene)
33%
Ontario has just started to report these indicators so it is too early
to tell if they are improving, and there are no international
benchmarks available yet. Even though there is a tendency for
LTC residents to decline over time, effective care can help to slow
the rate of decline and research shows that there is still room for
improvement in each of these areas.
Percentage of residents with pain that got worse recently†
12%
Percentage of residents with worsening† symptoms of depression
or anxiety
26%
Percentage of residents whose language, memory and thinking
abilities have decreased recently†
13%
Percentage of residents with recent†† unintended weight loss
7.1%
Visit http://www.hqontario.ca/en/ltc_landing.php for more
information on individual homes.
Data source:
*Continuing Care Reporting System, April 2009 to March 2010, calculated by Canadian Institute for Health Information. Under the system, every resident undergoes a detailed assessment
using the Resident Assessment Instrument — Minimum Data Set (RAI-MDS) 2.0 tool of his or her health at least once every three months by a staff member at the home specially trained to
collect this information. MOHLTC has implemented RAI-MDS in all LTC homes across the province. Results are based on 626 homes that have enough data to report.
†
From one assessment period to the next — typically, every three months.
††
A 5% loss over three months, or a 10% loss over six months.
Please see section 54 for root causes and ideas for improvement.
52
3.5 Keeping people healthy in home care
HOSPITAL
3.5
Keeping people healthy in home care
People who have chronic conditions or complex needs and require healthcare or personal support services
(such as homemaking) for 60 days or longer are referred to as long-stay home care clients.327 As people age,
it often becomes harder for them to live independently. However, home care workers can slow this process
for some clients.
LONG-TERM CARE
HOME CARE
PRIMARY CARE
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Home care clients preserve their wellbeing and ability to function as long
as they can, through activities to preserve bladder function and mobility,
control pain, preserve communication
ability, memory and thinking abilities,
and avoid depression and weight loss.
Without bladder function and mobility, home care clients may experience
loss of independence, reduced quality of life and increased risk of pressure
ulcers. Without appropriate pain control and activities that stimulate their
minds, they may endure needless suffering, be unable to participate in activities and feel social isolation. Depression and a loss of appetite can lead to
decreased energy, mood and mobility, and premature death.
Ontario’s 185,000 clients who
receive services through CCACs
on any given day328 and the over
600,000329 clients who received
home care services from
CCACs in 2009. Many of these
individuals are long-stay clients.
Value*
Percentage of clients
whose bladder
function has recently
declined or, if they
had a bladder function
problem, it did not
improve compared to
previous assessment
50%
Percentage of clients
with a new problem
with normal, everyday tasks (getting
dressed, eating,
personal hygiene) or
an old problem that is
not getting betters
46%
Percentage of clients
with pain that is not
well controlled
24%
Time trends & comparisons
Bottom line
100
Percent
Indicator
50
BETTER
0
Jul – Sep 07
Jan – Mar 10
Percent
100
50
BETTER
0
Apr– Jun 07
Jan – Mar 10
Among home care clients, close to 50% have a new
problem negatively affecting their ability to carry out
their activities of daily living or an older problem that
has worsened since their last assessment. The issue of
worsening activities of daily living has become more
common in the last three years. Because a decline in
one’s ability to perform activities of daily living is one of
the leading predictors of someone requiring institutional
care, improvement in this area is crucial.
Almost a quarter of home care clients experiencing
pain are not having their pain well managed. This has
not improved in the last three years. There is room
for improvement.
100
Percent
Half of individuals receiving home care services either
failed to improve or experienced a recent decline in their
bladder function compared to their previous assessment.
This indicator has not improved in the last two years.
There are many ideas for improving incontinence (see
section 3.4); it will be important to ensure we are using
all these ideas to the fullest.
50
BETTER
0
Apr– Jun 07
9.2%
100
Percent
Percentage of clients
with serious signs
of depression (e.g.,
profound sadness,
withdrawal from
normal activities)
Jan – Mar 10
50
BETTER
0
Apr– Jun 07
51%
100
Percent
Percentage of clients
who recently declined
or did not improve
in their language,
memory and thinking
abilities
Jan – Mar 10
50
BETTER
0
Apr– Jun 07
Jan – Mar 10
Among all home care clients, one in 10 exhibit a sad
mood and at least two depressive symptoms. There has
been no change in the last three years. These results are
better than in several European countries (average 12%),
but Finland and Sweden have the best results (2.1% and
4.1% respectively).330 This suggests that there is still
room for improvement.
Half of all people receiving home care services
experienced a decline in their thinking abilities or
a failure to show improvement in an existing problem
over the previous six months. This problem has become
more common in the past three years. Managing
people with cognitive impairment will be an increasingly
important issue as the population ages. There is
room for improvement.
Data source:
*Home Care Reporting System, FY 2009/10, calculated by Canadian Institute for Health Information. Under the system, every long-stay home care client undergoes a detailed assessment using
the Resident Assessment Instrument — Home Care (RAI-HC) tool of his or her health at least once every six months by someone specially trained to collect this information. The following RAI-HC
indicators were adjusted for various risk factors: failure to improve/incidence of bladder incontinence; failure to improve/incidence of activities of daily living (long form) impairment; prevalence of
inadequate pain control among those with pain; prevalence of negative mood; failure to improve/incidence of cognitive decline; and prevalence of weight loss.
53
3. Effective
3.5
Root Cause
Ideas for Improvement
Issue: Bladder incontinence.
Staff lack familiarity with strategies such as
prompted voiding to reduce incontinence.284
Residents might find it uncomfortable or
unnatural to go to the bathroom on schedule.
Staff training and standard protocols for implementing prompted voiding routines have been shown
to improve continence in LTC.285 With this approach, staff remind residents to void at certain times in the
day, which helps avoid accidents. Ensure new or short-term staff are familiar with these techniques or
partnered with those who are. The Registered Nurses’ Association of Ontario has workshops and
materials to support these strategies.286,287
Issue: Decline in mobility.
Residents underuse mobility aids, such as
canes or walkers, even though they are known
to prevent falls.288,289 This could be due to
feelings of embarrassment about using them,
because they are uncomfortable, because they
don’t know how to use them, or because they
were never offered.
Encourage use of mobility aids. Connect residents with others who have overcome shame of
mobility aids and who now live more active lives. Ensure that users are well trained and comfortable
with how to use them.
Lack of exercise or rehabilitation, because
services are not available, not tailored to the
individual’s needs or too expensive.
Offer a variety of different exercise or rehabilitation therapies.292 A systematic review determined
that exercise interventions reduced the risk of falls in the elderly by 14%.293
Make assessment of the need for mobility aids routine, and conduct systematic checks of
mobility aids to ensure they are appropriate. The RAI-MDS 2.0 tool provides guidance on how and
when to assess residents’ use of mobility aids.290,291
Ensure residents are capable of using devices and are trained in their proper use. Some
devices require the user to have appropriate cognitive function and strength to use them properly
and not increase the risk of falls.
Issue: Pain.
Providers have difficulty recognizing pain,
particularly among residents with dementia.294,295
Use a validated pain assessment tool. Several pain assessment tools exist that are designed as
checklists and that use visual cues, such as facial expressions and changes in behaviour, to recognize
pain.296,297,298 A review that rates pain recognition tools by validity, reliability and feasibility can be found
here: www.biomedcentral.com/content/pdf/1471-2318-6-3.pdf. RAI-MDS 2.0 also provides for regular
assessment of pain.299
Make the use of these pain assessment tools a part of routine assessments of residents.
Train all staff in their use.
Residents may be reluctant to take
pain medications due to fear of addiction
or tolerance or dislike of side effects
(e.g., constipation).
Physicians may be reluctant to prescribe
pain medications.
They may worry that residents will become
addicted; this is a particular concern with
narcotic agents.
Age can affect a drug’s effectiveness,
sensitivity and toxicity, and it may be difficult
to predict optimal dosages and potential
side effects.300
54
Guidelines are useful in helping staff manage persistent pain and assess responsible medication
use. Develop standardized protocols for pain control, agreed to by all staff, outlining how to use
short-acting and long-acting narcotics.
Maximize use of safe medications, such as acetaminophen. Consider adding non-addictive drugs for
chronic pain (e.g., low-dose nortriptyline or gabapentin).301 Also consider non-drug alternative therapies
for pain control, such as acupuncture,302 exercise or physical therapy.303
Consider adopting a “universal precautions” approach,304 assessing every resident for risk factors
associated with addiction using brief screening tools.305,306,307 Employing these tools can increase
confidence in prescribing and monitoring the use of drugs and help identify patients for whom more
intensive monitoring is appropriate.
3.5 Keeping people healthy in home care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Issue: Depression.
Residents experience social isolation,
especially with the initial move to LTC.308
A decline in general health or physical or
psychological capacity may make people
feel depressed, especially if it limits their
daily activities.319
Changes in the brain may make older
people more vulnerable to depression.320
Offer a range of social activities, such as exercise classes, field trips, music and art classes,
activities that provide opportunities for intergenerational mixing and pet therapy. Group activities address
feelings of isolation and loneliness.313,314 Activities are especially likely to prevent (or alleviate) depression
when they engage residents’ interests, rather than just occupying their time. Ensuring residents are able
to choose activities is especially important.315
Offer counselling or antidepressant medications.316,317,318
Deaths of friends or family, which
become more common with age,
can lead to depression.321
Staff may not recognize depression in
older people, as it frequently differs
compared to depression that occurs earlier
in life, or it may be considered a “natural”
part of aging.322,323
Screen for signs of depression using the RAI-MDS 2.0 tool or other validated depression scales.309,310,311,312
Better equip staff to identify and manage depression in residents. Knowledge of the ways in which
age may alter factors associated with the onset and persistence of depression is essential for effective
treatment of depressed older adults.324
What is Ontario doing?
t The Residents First Initiative: Advancing Quality in Long-Term Care, now in its second year, supports LTC homes to use quality improvement
techniques to improve the delivery of care. Approximately 75% of LTC homes are participating in the Leading Quality Program, which helps leaders
incorporate quality as a core organizational strategy.325 Roughly 20% of LTC homes are completing structured quality improvement training that
focuses on improving resident care across a number of clinical areas, such as falls prevention and continence care. It is anticipated that many
more homes across the province will take advantage of this training opportunity.
t MOHLTC is implementing a new inspection methodology for LTC homes. LTC homes can replicate the comprehensive Resident Quality Inspection
as they work to improve resident care.326
55
4. Safe
4.1
Hospital infections
Infections acquired in a hospital waste healthcare resources. They also cause patients to suffer and sometimes result in death.331 Hospitals
have an obligation to do everything they can to prevent hospital-acquired infections.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
As few hospital-acquired infections as possible.
Unless Ontario eliminates hospital-acquired infections, Ontarians will continue
to bear the burden of unnecessary deaths, longer hospital stays, more hospital
costs, more disability and more psychological effects.332
Hospitals to adopt evidence-based prevention
practices, including effective hand washing and
protocols to prevent surgical site infections.
Without complete adoption of effective prevention practices, Ontarians will
experience more hospital-acquired infections.334, 335
Ontario’s hospital
patients; each year
there are nearly
1.1 million hospital
discharges in Ontario.333
Value*
Hand hygiene compliance
in hospitals before patient
contact
Overall
Time trends & comparisons
Bottom line
100
66%
Percent
Indicator
50
BETTER
0
2008/09
Acute teaching
Large community
Small community
Chronic/rehabilitation
Mental health
2009/10
Two in three Ontario healthcare providers wash their
hands before seeing patients, while almost eight in 10
wash their hands after patient contact (data not shown).
Acute teaching hospitals have a lower rate of hand
hygiene compliance compared to other hospital types.
There has been some improvement, but compliance is
still too low. There is room for improvement.
57%
70%
71%
69%
63%
0
50
100
Percent
0.30
1.0
BETTER
Rate
New hospital-acquired
C. difficile rate per 1,000
bed days
0.5
0.0
New ventilatorassociated pneumonia
(VAP) cases per quarter
77
New central line infection
(CLI) cases per quarter
53
Aug 08
Jan 11
Number of cases
200
100
0
Jan – Mar 09
TARGET
Oct – Dec 10
The C. difficile infection rate has been stable throughout
2010 at around 0.30 cases per 1,000 bed days. This
corresponds to about 250 cases per month across the
province. These results represent an improvement compared to late 2008, when C. difficile reporting began.
Activities in Ontario which may have contributed to this
decline include the creation of standard protocols336 and
infection control resource teams337 to help hospitals deal
with outbreaks. Ontario’s rates compare favourably to
other places,338 but there is still room for improvement.
The number of VAP and CLI cases has decreased steadily
over the last two years. Many hospitals in Ontario have
participated in the Safer Healthcare Now! campaign
which supports hospitals to implement best practices for
avoiding these infections,339 and this may have contributed to the decrease. This improvement is welcome,
because these infections are associated with a high
mortality rate.340, 341 However, there is still room to do
better, as these infections can be eliminated altogether,
and many hospitals have already done so.342,343
Data source:
*MOHLTC. See also www.ontario.ca/patientsafety. Most recent values: C. difficile, MRSA, VRE — average over 2010; VAP, CLI, SSI – October to December 2010; hand hygiene – FY 2009/10.
VRE cases include only those that result in bacteremia (infection in blood); VAP cases include only those occurring in intensive care units (ICU) after at least 48 hours of mechanical ventilation;
CLI cases include only those occurring in the ICU after at least 48 hours of being placed on a central line. Hand hygiene compliance represents percent of instances where proper hand hygiene
took place when it should have.
56
4.1 Hospital infections
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Value*
New hospital-acquired
Methicillin-resistant
Staphylococcus aureus
(MRSA bacteremia)
cases per quarter
53
Bottom line
6
Number of cases
80
New hospital-acquired
Vancomycin-resistant
Enterococci (VRE)
bacteremia cases
per quarter
BETTER
40
0
Oct – Dec 08
97%
TARGET
50
0
Jan – Mar 09
In the year 2010, there were 210 cases of MRSA
bacteremia and fewer than 24 cases of VRE bacteremia
reported in hospitals across Ontario. MRSA infections
have not changed in the last two years, but VRE cases
have decreased compared to 2009. Continued vigilance
with hand washing and infection control practices is
needed to ensure these rates do not increase.
Oct – Dec 10
100
Percent
Percentage of hip and knee
replacement surgeries
where antibiotics were
given at the right time
to prevent surgical site
infection
Time trends & comparisons
Oct – Dec 10
The use of the right antibiotics at the right time for hip
and knee surgery has increased from 85% to 97% over
the past two years. Many hospitals have achieved 100%
by using standard protocols before surgery.344 All hospitals should implement standard protocols and ensure
that antibiotics are given at the right time for other types
of surgery.
Data source:
*MOHLTC. See also www.ontario.ca/patientsafety. Most recent values: C. difficile, MRSA, VRE — average over 2010; VAP, CLI, SSI — October to December 2010; hand hygiene — FY 2009/10.
VRE cases include only those that result in bacteremia (infection in blood); VAP cases include only those occurring in intensive care units (ICU) after at least 48 hours of mechanical ventilation;
CLI cases include only those occurring in the ICU after at least 48 hours of being placed on a central line. Hand hygiene compliance represents percent of instances where proper hand hygiene
took place when it should have.
57
4. Safe
4.1
Root Cause
Ideas for improvement
Lack of urgency or sense of importance in
tackling hospital infections within the organization or staff.
Exert strong leadership to develop of a culture of safety. This may include any of the following:
t Leaders can deliver frequent messages to staff about the importance of safety and the
organization’s commitment to improve. Delivering these messages in person (e.g. through
walkarounds with staff)345 can be more powerful than by print.
t Leaders can also reinforce the message about the importance of reporting safety incidents or
deficiencies, and that staff will be supported rather than punished when they do so.
t Offer rewards or recognition to units or programs for achieving infection control benchmarks.
Promote those successful at improving safety to prominent positions.
t Leaders can use regular safety culture surveys of employees to monitor how strong the safety
culture is within the organization.346
Providers may forget to follow all recommended procedures for infection control.
Use checklists and flow sheets to prompt action. For ventilator-associated pneumonia, use checklists to remind everyone to keep the head of the bed at 45 degrees, try daily sedation breaks, and
enact other best practices.347, 348 For surgical site infection prevention, checklists before surgery can
ensure the right antibiotics are given at the right time.349, 350 Give cleaning staff a checklist of
items that require daily cleaning or cleaning at discharge.351
The Keystone ICU project in Michigan implemented a five-step checklist to reduce catheter-related
bloodstream infections, which helped decrease the infection rate from 2.7 infections per 1,000
catheter days to zero.352
Lack of experience.
Ensure that only those trained to do intensive care medicine work in ICUs.353, 354, 355
Ensure that all new or temporary staff are oriented to infection control procedures. Develop
a process to verify their skills or compliance with protocols early in their time with the organization.
58
Providers are unaware of how poorly they
are following infection control guidelines.
Regularly monitor compliance with protocols and report on performance.356, 357 Although the
province mandates public reporting on many key measures, leaders can consider posting this
information within the hospital more prominently, or breaking down statistics by individual department358 or type of provider (e.g. hand hygiene compliance among physicians, nurses, etc.). While
some measures such as C. difficile must be collected monthly, hand hygiene reporting is mandated
in Ontario only once a year. Hospitals that are aiming for faster improvement may consider collecting
and reporting this data to staff much more frequently.
Providers may be reluctant to follow
infection control guidelines if they are
skeptical of the evidence or don’t think
it is a problem for them.
Explore strategies for healthcare provider buy-in. Identify leaders or champions359 in different
professions in the hospital (e.g., doctors, nurses, administrators) to work with those refusing to comply.
Review clinical evidence. Look at the hospital’s infection statistics and make the case for change.
Use existing evidence-based tools360 and work with all providers’ ideas to make the process as efficient
as possible. Work with administration and the hospital board to revoke privileges for staff and
professionals who refuse to practice at the standard of care.361
4.1 Hospital infections
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for improvement
Issue: Poor compliance with hand hygiene protocols.
No clear accountability to the patient.
Encourage patients and families to take a more active role in hand hygiene promotion.
Create tools (e.g., brochures, posters, videos, buttons) that educate them on when, why and
where hand hygiene tasks should be performed and give them explicit permission to ask or remind
healthcare providers to follow hand hygiene protocol.362, 363
Healthcare providers may feel that they
don’t have time to wash their hands.364
Work hand washing into routines, such as washing hands when first meeting patients.
Hand hygiene stations are not
conveniently located.
Put hand washing stations in convenient areas,365 such as in patient rooms, at the entrance to
rooms, at the entrance to wards and by elevator doors. Provide alcohol-based hand rub at patient
bedsides. Regularly inspect stations to ensure they are not empty.
Hand washing solution and alcohol-based gels
may irritate skin and cause chapped hands.366
Provide soaps or hand sanitizer products that have moisturizers.367
What is Ontario doing?
t )
PTQJUBMTBSFSFRVJSFEUPJNNFEJBUFMZSFQPSUC. difficile outbreaks to their local public health units. This gives medical officers of health the
information they need to monitor and respond to emergent outbreaks. Infection control resource teams are available to help hospitals respond
to outbreaks.368
t 5
IFIBOEIZHJFOFQSPHSBNGPS0OUBSJPIPTQJUBMT‰+VTU$MFBO:PVS)BOET‰XBTMBVODIFEJO.BSDI)PTQJUBMTBSFSFRVJSFEUPQVCMJDMZ
report hand hygiene compliance among healthcare workers.
t 5
IFSFBSF3FHJPOBM*OGFDUJPO$POUSPM/FUXPSLT3*$/T
BDSPTTUIFQSPWJODFUIBUQSPNPUFUIFCFTUBQQSPBDIFTUPJOGFDUJPOQSFWFOUJPO
and control.369
t 4JODF0OUBSJPIBTQSPNPUFEQVCMJDSFQPSUJOHPGIPTQJUBMBDRVJSFEJOGFDUJPOJOEJDBUPSTCZJOEJWJEVBMIPTQJUBM370
t 5
ISFF0OUBSJPIPTQJUBMTBSFQBSUJDJQBUJOHJOUIF$BOBEJBO1PTJUJWF%FWJBODFQSPKFDUBTQJMPUTJUFT371 This approach identifies individuals who follow
a beneficial practice when most others do not, uncovers the secret behind their behaviour and aims to spread it to others.
59
4. Safe
4.2
Adverse events in acute care hospitals
When a patient experiences an unintended, undesirable change in health caused by healthcare services, it is described as an adverse
event.372, 373 According to a Canadian study, 37% of adverse events are preventable, often because they are due to medical error.374
Examples of medical errors include forgetting to give a drug or treatment, giving the wrong treatment, doing a procedure with improper
technique, not recognizing a warning sign early or making the wrong diagnosis.375, 376
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Surgery patients experiencing as few pulmonary embolisms (blood clots in the lung) or
deep vein thrombosis (DVT; blood clots in
the leg) as possible, through the use of blood
thinners and encouraging people to be up and
about where possible.377
Blood clots in the legs can break off and end up in the lungs, leading to a
pulmonary embolism. The chance of death is 5% from DVT and 33% from
pulmonary embolism.378 Pulmonary embolism is the most common preventable cause of hospital death,379 and DVT can lead to long-term problems with
blood circulation in the leg.380 DVT and pulmonary embolism also increase
hospital costs.381
Use of best practices like the surgical checklist, to ensure 26 key tasks are always carried
out by operating room teams.
Use of the surgical checklist has been shown to reduce deaths and complications following surgery.384
Ontario’s surgery
patients; in FY 2009/10,
there were 1,207,000
day surgeries382 and
285,000 acute in-patient
surgical discharges383
in Ontario.
No “never events”, such as surgery on the
wrong site or wrong patient,385 which are
clearly due to a failure to follow standard procedures. This report examines one type of never
event: a foreign object left inside the patient
after a procedure.
Never events have devastating consequences for patients. In the case of
retained foreign objects, they include infections, pain, unnecessary repeat
surgery or death. Reactions to these events from patients, families and the
community include anger and loss of trust. Hospitals pay for both the costs
of additional care and potential lawsuits. Hospital staff may suffer terrible
guilt from these events.
All hospital patients avoiding harm from their
medical care. Specific examples include falls,
pressure ulcers, bladder infections and pneumonia – events that occur less frequently when
the right level of nursing care is provided.387
Adverse events can cause pain and suffering, unintended injuries, disability,
longer stay in hospital and increased risk of death.388, 389, 390
Adjusted rate of in-hospital pulmonary
embolism and DVT per 100 surgical
procedures:
DVT
Pulmonary embolism
Sum of DVT and pulmonary
embolism
Time trends & comparisons
Bottom line
0.6
BETTER
0.20*
0.32*
0.52*
0.3
0.0
2002/03
2009/10
100
98%**
BETTER
Percent
Percent of surgeries in which a surgical
safety checklist was performed
Value
Rate
Indicator
Ontario’s hospital
patients who account
for more than 1.1 million
hospital discharges each
year.386
50
Following a surgical procedure, one in 200
patients develop a serious blood clot. In
the past two years, these rates have not
improved, and in fact the rate of pulmonary embolism has increased. This may
reflect improved reporting and focus on
this issue. There is room for improvement.
Use of the surgical checklist is now just
under 100%, which is welcome news. It
will be important to monitor its impact in
reducing deaths and complications in the
near future.
0
Apr–Jun 10
BETTER
2.1***
0.8
15
10
7.5
Over the past two years, rates of these
adverse events have either increased or
remained stable. This increase may be
a result of increased reporting of these
events. There is room for improvement.
0.0
2007/08
9.9***
2009/10
20
BETTER
Rate
Cases per 100,000 procedures where
a foreign object was left in the patient
15.0
Rate
Rates of adverse events per 1,000
medical/surgical patients in hospital:
Pressure ulcer
Fracture
Urinary tract infection
Pneumonia
Jul–Dec 10
10
0
2006/07
2009/10
In about one in ten thousand procedures
in Ontario, a foreign object was left in the
patient. This rate has increased in recent
years, although this could be due to increased reporting of these events. Although
these instances are rare, they can cause
serious harm and should never happen.
Data sources: *Discharge Abstract Database (DAD), FY 2009/10, calculated by Institute for Clinical Evaluative Sciences. **Web-enabled Reporting System (WERS) or Surgical Efficiency Target
Program (SETp), hospital self-reported data, July to December 2010, provided by MOHLTC. ***DAD, FY 2009/10, provided by the Canadian Institute for Health Information (CIHI), FY 2009/10.
60
4.2 Adverse events in acute care hospitals
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Healthcare providers may not follow best
practices because they are busy, distracted by
other patient issues or there are too many things
to remember.
Use standardized admission orders, checklists, order sets or decision support tools.391
Examples include:
t Standard risk scoring sheets to identify people at high risk for venous thromboembolism392, 393
falls or ulcers394;
t Checklists to remind staff to follow recommended practices for falls prevention for those at
high risk395 (e.g. keep bed low, make call bell or commode easily accessible, provide no-slip
footwear, check for clutter, arrange for physiotherapy or assistive devices for walking; see
sections 4.5 and 4.6);
t Checklists of best practices for pressure ulcer prevention (e.g., special mattresses or padding,
turning immobile patients regularly, placing labels in chart or by bed to remind staff who is at
high risk of an ulcer);396, 397
t Visual reminders and cues to help staff spot any evidence of new pressure ulcers in patients on
their unit.398 (See section 4.5.)
Providers are unaware of how significant a
problem adverse events are.
Routine performance monitoring and feedback.399 Feed back data to surgeons on their rate of
pulmonary embolism and DVT or compliance with the use of blood thinners. Regularly feed back data
to nurses on nursing-sensitive adverse events.
Healthcare providers make judgment errors
because of fatigue.400
Set limits on on-call hours. Hospitals can set policies to limit the consecutive hours on call or
require rest time after being on call.
Focus on healthcare provider wellness.401 This includes ensuring providers have proper nutrition
and hydration throughout their shifts.402
Staff have too little time to do all recommended procedures.
Increase available staff time. Many adverse events have been shown to occur more frequently
when there are fewer nurses available.403 Although increasing nursing staff time at the bedside can
be achieved by adding more nurses, it is also important to first consider how the same staff could
do more bedside care by eliminating unnecessary tasks or streamlining their work.404 Programs such
as “Releasing Time to Care” in the UK have redirected 18% of nurses’ time away from administrative
or non-clinical tasks back to direct patient care in selected pilot sites.405
What is Ontario doing?
t 5
IFExcellent Care for All Act, enacted in June 2010, requires hospital boards to make certain that the administrator establishes a system that
ensures a disclosed incident is analyzed and a plan is developed with systematic steps to avoid/reduce the risk of further similar incidents.406
61
4. Safe
4.3
Mortality in hospitals
Hospitals try to provide patients with timely service, a positive experience and recovery from their medical condition — but most critical of
all is their ability to save lives. Despite complex, challenging situations, hospitals must apply appropriate treatments and avoid medical
errors that can lead to needless deaths. There are two main ways to measure mortality: the hospital standardized mortality ratio (HSMR†),
which compares how many deaths occurred to what might be expected given the types of cases the hospital sees, and mortality rates for
specific medical conditions.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Mortality rates for hospital patients that are as low as possible for:
Higher mortality rates are
clearly undesirable.
Ontario’s hospital
patients who account
for more than 1.1
million hospital
discharges each
year.412
t )FBSUBUUBDLT
t 4VSHFSZBOEQSPDFEVSFTTVDIBTDPSPOBSZBSUFSZCZQBTTHSBGUTBOEQFSDVUBOFPVTDPSPOBSZ
interventions ; and,
t 0
UIFSDPNNPODPOEJUJPOTJODMVEJOHDPOHFTUJWFIFBSUGBJMVSFQOFVNPOJBDISPOJDPCTUSVDUJWF
pulmonary disorder (COPD), septicaemia, lung cancer, stroke, respiratory failure and hip fracture.
Ontarians want hospitals to do everything possible to prevent deaths, including:
t &OTVSFQBUJFOUTHFUUIFSJHIUESVHTUFTUTBOEUSFBUNFOUT
t ' PMMPXIBOEXBTIJOHSPVUJOFTQSPUPDPMTUPQSFWFOUTVSHJDBMTJUFJOGFDUJPO407 and blood clots,408
and use surgical checklists409;
t %PDPNQMJDBUFEQSPDFEVSFTPOMZJGUIFZIBWFBOBCVOEBODFPGFYQFSJFODF
t /PUEFMBZUJNFTFOTJUJWFUSFBUNFOUTTVDIBTDMPUCVTUFSTGPSIFBSUBUUBDLBOETUSPLF410 and
antibiotics for serious infections; and,
t *NQMFNFOUJOGPSNBUJPOUFDIOPMPHZTZTUFNTBOENFEJDBUJPOSFDPODJMJBUJPOUPQSFWFOUESVHFSSPST411
Percentage of reportable hospitals whose
HSMR has decreased
compared to the previous year
Value
Time trends & comparisons
Bottom line
100
BETTER
69%*
Percent
Indicator
50
Last year, almost seven out of 10 reportable hospitals experienced a decrease in their HSMR score. There have been
substantial improvements within the last four years; however,
there may still be room to improve.
0
2005/06
16*
25.0
BETTER
Rate
Adjusted in-hospital
rate of death within 30
days per 100 patients
admitted for stroke
2009/10
12.5
About one in six stroke patients die within 30 days of a
stroke. There has been minor improvement over the past
four years. This implementation of the Ontario Stroke Strategy (see next page) may have contributed to this trend.413
There is still room to improve.
0.0
2003/04
9.6**
25.0
BETTER
Rate
Adjusted rate of death
within 30 days per
100 patients admitted
for heart attack
2009/10
12.5
One in 10 patients die within a month of having a heart
attack. Continuous decline in mortality in the past six years
may be due to newer treatments (e.g., bypass or stents following a heart attack) and increased use of life-saving drugs
such as statins (see section 3.1).
0.0
2002/03
3.0
BETTER
2.1**
Rate
Adjusted rate of
death within 30 days
per 100
coronary artery
bypass grafts
percutaneous
coronary
interventions
2008/09
1.5
0.78**
0.0
2002/03
2008/09
Approximately one in 50 people die after having a coronary
artery bypass graft one in 135 people die after having a
percutaneous coronary intervention. The mortality rates
for these services were higher in 2008/09 than in previous
years, although it is possible that this increase could be due
to more high risk patients undergoing and benefitting from
these procedures.†† It will be important to further investigate
causes for this recent increase and ensure recommended
guidelines are followed.
Data sources: *Canadian Institute for Health Information, FY 2009/10.
**Discharge Abstract Database, Registered Persons Database, FY 2008/09, calculated by Institute for Clinical Evaluative Sciences.
†
The HSMR is the ratio of actual (observed) deaths to expected deaths. It focuses on the diagnosis groups that account for the majority of in-hospital deaths. Using a logistic regression model, it is
adjusted for several factors that affect in-hospital mortality, including age, sex, length of stay, admission category, diagnosis group, co-morbidity and transfer from another acute care institution. An
HSMR of 100 suggests that a hospital’s mortality rate is the same as the national average, given the types of patients cared for. An HSMR greater or less than 100 suggests that a local mortality
rate is higher or lower, respectively, than the national experience. See secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hsmr_results_home_e.
††
This indicator has been case-mix-adjusted for factors including age, gender and existence of certain conditions (e.g. diabetes, congestive heart failure, past heart attack or kidney failure), but not for
factors such as the urgency of the surgery. Future versions of this indicator will aim to include this information.
62
4.3 Mortality in hospitals
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
See sections 3.1, 4.1 and 4.2 for specific change ideas related to heart attack, stroke, congestive heart failure, hospital infections and pulmonary
embolism that could affect mortality.
Root Cause
Ideas for improvement
Healthcare providers may find it difficult
to consistently follow all life-saving best
practices. This could be because they are busy
or overwhelmed with too much information and
forget, or are not aware of the latest evidence.
Increase the use of standardized admission orders, discharge checklists, order sets and
decision support tools.414 In addition to the tools mentioned in sections 4.1 and 4.2 (e.g. checklists
for surgery, falls, ulcers, deep vein thrombosis), hospitals can use “care bundles,” or checklists of
accepted clinical guidelines printed on forms that are made conveniently available to clinicians.
Hospitals in the UK have used these bundles for stroke, congestive heart failure and chronic obstructive pulmonary disease to reduce mortality.415 Different bundles for sepsis exist, and their use is
associated with a doubling of the odds of survival.416, 417 The Canadian Patient Safety Institute and
UIF4BGFS)FBMUIDBSF/PX*OJUJBUJWF418 promotes Canadian care bundles that cover topics such as
ventilator-associated pneumonia, central line infections and medication reconciliation.
Facilities and providers may be inexperienced
at handling certain conditions. Mortality rates
are lower for esophageal, pancreatic and liver
cancer surgery,419 cardiac surgery,420 pulmonary
embolism,421 abdominal aneurysm repair422 and
carotid endarterectomy423 when done by doctors
and in hospitals that perform more surgeries.424
Create dedicated centres of excellence. Canadian stroke guidelines recommend that patients be sent
to designated stroke centres whenever possible,425 as such centres have better outcomes.426 Ontario’s
stroke system follows this model (see below). This principle can be followed for other diagnoses.
Delivery of time-sensitive care is delayed. It
is important for heart attack patients to get
thrombolysis or surgery quickly,432 for stroke
patients to get thrombolysis433 and for pneumonia
patients to get antibiotics as soon as possible.
Develop standardized processes or put clinical pathways in place. Improve emergency department triage processes.434 Identify in advance who does what, when and in what order. For example, at
the Windsor Essex District Stroke Centre, there is an acute stroke protocol facilitating thrombolysis, an
acute stroke clinical pathway and order set supporting current best practice, multidisciplinary stroke
care, a neurology unit providing high-level multidisciplinary expert care, onsite CT, MRI, interventional
radiological, neurosurgical and vascular surgery services, and an acute stroke resource nurse who
provides case management, as well as professional and patient education.
Failure to rescue. Warning signs of rapid
deterioration might not be recognized because
the diagnostic cues are subtle and unrelated,435
or they may not be acted on quickly because of
poor communication, shift changes or being too
busy or distracted.
Consider the use of rapid response teams,436 with clear guidelines for when they are to be
used. Rapid response teams are clinical teams with critical care expertise who can be called at a
moment’s notice by anyone to assess and stabilize a patient whose condition is deteriorating.437, 438
Consider performing high-risk surgeries only in facilities that maintain a “threshold volume”
of cases,427, 428, 429, 430 and where only surgeons with a minimum volume per year do the surgery. Currently, in cardiac care, there are minimum standards for facilities that are being followed. Cancer Care
Ontario has released a minimum volume standard for hepatic-pancreatic-biliary tract surgery to improve
outcomes for cancer surgery patients. These standards include minimum volumes of surgeries, a
minimum number of surgeons and a minimum of necessary physical resources and human resources
that must be available.431
Consider addressing critical reasoning skills439 and teaching communication techniques, such as
“situation-background-assessment-recommendation,” which can help nursing staff accurately describe
the critical nature of a situation to a physician or nurse practitioner.440 Also consider teaching the
critical language approach of “concerned-uncomfortable-unsafe-scared,” which helps providers raise
issues related to patient safety.441
What is Ontario doing?
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healthcare teams from 161 organizations have enrolled, representing almost half of all teams enrolled across the country. The greatest uptake is
with medication reconciliation in acute care (162 teams) and surgical site infection prevention (159 teams).442 Other teams are working on
reducing hospital acquired infections, creating rapid response teams, preventing blood clots, reducing falls and optimizing care for heart attacks.
t 0
OUBSJPTTUSPLFTZTUFNIBTOJOFSFHJPOBMBOEEJTUSJDUTUSPLFDFOUSFTFBDIXJUIFYQFSUJTFBOESFTPVSDFTUPHJWFTQFDJBMJ[FETUSPLFDBSF443
Ambulances bypass other hospitals to go directly to these centres.
63
4. Safe
4.4
Drug safety in long-term care
Medications, which can save lives and improve quality of life, may have side effects. Those side effects may be more severe for elderly
people, who often have more complex medical problems that interact with the drugs.444 This makes drug safety a very important issue in
long-term care (LTC) homes. Many adverse drug events can be prevented445 — for example, by steering clear of drugs known to be
dangerous for the elderly,446 by avoiding confusion on which drugs or doses a resident should be taking and by monitoring those drugs
once a resident is receiving appropriate therapies.447
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Medications with serious side effects for
the elderly are avoided when there are safer
alternatives available. LTC staff can consult the
“Beers” list of drugs to avoid448 and the Agency
for Healthcare Research and Quality (AHRQ)
“never prescribe” list of drugs.449
Medications on the Beers and AHRQ lists may increase the risk of falls and
cause dizziness, confusion or death. They may also lead to irritating side
effects, such as dry mouth.
Ontario’s 75,000 residents in 626 LTC homes
across the province.450
Prescriptions to LTC residents for antipsychotic
or anti-anxiety drugs are avoided unless there
is a specific reason.
Antipsychotic and anti-anxiety drugs may increase the risk of falls451 and
cause dizziness, confusion, stroke or death.452
Percentage of new LTC home
residents (aged 66 and above)
newly started on certain drugs
where there was no clear reason
to use them:
Antipsychotics
Benzodiazepines
Time trends & comparisons
Bottom line
50
19%*
Percent
Percentage of elderly LTC residents prescribed the following:
A drug that should be
avoided for the elderly
(Beers list)
A drug that should never be
given to the elderly (AHRQ
list)
Value
25
BETTER
0
0%
2002/03
2008/09
50
14%**
24%
Percent
Indicator
25
BETTER
0
2005/06
2008/09
About one in five LTC residents in Ontario is
prescribed a drug that should be avoided in the
elderly. The use of these drugs has gradually
decreased over the last seven years, but there is
likely still room for improvement. The good news
is that the use of drugs that should never
be given in this population remains at 0%.
Shortly after entering an LTC home, one in six
residents are given an antipsychotic drug that
they were not receiving before (i.e., the LTC
home physician and not the previous family
doctor started the drug). One in four of these new
residents are prescribed a drug for anxiety or
sleep that they were not receiving before. Over
the past three years, there has been no change
in the prescribing of new antipsychotics, and only
a very slight decrease in the use of new benzodiazepines. Although there is no target for how low
the use of these drugs should be, there is likely
major room for improvement.
Data sources:
*Registered Persons Database (RPD), Ontario Drug Benefits Database (ODBD), Ontario Health Insurance Plan (OHIP) Claims Database, Discharge Abstract Database (DAD), FY 2009/10, calculated by
Institute for Clinical Evaluative Sciences (ICES).
**RPD, ODBD, OHIP Claims Database, DAD, Client Profile Database, FY 2009/10, calculated by ICES.
64
4.4 Drug safety in long-term care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for improvement
Inappropriate resident behaviours, such as aggressiveness, lead to the prescription of antipsychotics or
sedative-hypnotic drugs.
Encourage non-drug approaches to managing inappropriate behaviour.453
These include conflict de-escalation and good communication techniques, such as
making good eye contact, using simple sentences and one-step instructions, and
avoiding making the resident feel rushed.454 Cognitive-behavioural therapy may be
helpful for certain types of elderly persons455, to address the underlying cause of anxiety.
Look to the Resident Assessment Protocol in the RAI-MDS 2.0 assessment tool, which
is designed to guide care planning for a resident exhibiting aggressive behaviour.
Difficulty stopping drugs that patients have been on for
years, because of an addiction or tolerance to the drug.
Withdrawal symptoms like insomnia or headaches might appear
when a drug is stopped.456
Gradually wean residents off these drugs over a period of several weeks. Standard
protocols457 could help providers accomplish this.
Switch to safer drugs. For example, some antidepressants are preferable to
sedative-hypnotics for anxiety.458
Consider treatments for withdrawal side effects, such as carbamazepine for
benzodiazepine withdrawal,459 if slow tapering proves to be difficult.
Some LTC homes may have an internal norm where
heavy drug prescribing is viewed as standard care. In
one American study, residents entering a LTC home that already
had high prescribing rates for anti-psychotics were more likely
to be put on one without a clear indication.460
Physicians may be ordering high risk drugs because they are
unaware of the risks or available alternatives, or are
sceptical about the evidence that they can cause harm.
Public reporting of the use of these drugs by individual long-term care home can help
motivate homes with unusually high rates of prescribing to address the problem.
Provide anonymous feedback to individual physicians within a LTC home on their
rates of use of high risk medications, for their own improvement purposes.
Remove the most dangerous drugs from the formulary of LTC homes.
Implement a well-designed electronic medical record (EMR), which can provide
warnings about potentially harmful prescriptions.461 Use computerized physician
order entry (CPOE) with clinical decision support.462 When a particular drug is
selected, these systems can ask the prescriber if a checklist of other strategies have
been tried first.463 Consider academic detailing programs, where specially trained
individuals (typically pharmacists or nurses) visit practitioners to promote evidencebased drug prescribing practices. These have been successful at changing prescribing
practices.464, 465 Unlike drug companies, their information is unbiased.
Conduct regular medication reviews. While Ontario’s LTC homes are already required
to do so,466 these reviews could be strengthened by having pharmacists use checklists
or appropriateness criteria, or having an interdisciplinary team review drugs.467, 468
Feelings of loneliness, loss of autonomy or lack of
purpose may lead to anxiety or difficult behaviour.
Offer a range of social and recreational activities to residents to address feelings
of isolation and loneliness469, 470 and prevent or alleviate depression.471 (See section 3.4.)
Staff feel they do not have enough time to provide face-toface care that would allow them to help residents address
underlying issues behind anxiety or difficult behaviour.
Help staff spend more time in direct contact with residents. The Releasing Time
to Care program guides clinical teams as they identify and streamline processes in
order to free up staff time for activities that add value for residents.472
Residents entering a LTC home for the first time may face a
difficult adjustment period. Unfamiliar surroundings, different
routines and new people can worsen confusion or generate anxiety,
insomnia, or fear and aggressiveness. These symptoms, in turn,
may lead to greater use of antipsychotics or anti-anxiety drugs.
Consider improvements to orientation programs for new residents. This may
include more intensive time spent up front getting to know residents and families and
understanding their concerns, or better communication between staff in LTC and health
care workers looked after the resident while he or she was still in the community to
understand his or her medical and psychosocial needs.
What is Ontario doing?
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the use of medication incident report information, develop medication safety indicators, and implement the Medication Safety Self-Assessment program.473
t 0
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medications safely and effectively. Three new services are now available: MedsCheck for Diabetes, MedsCheck LTC and MedsCheck at Home.474
t 0
OUBSJP3FHVMBUJPOPGUIFLTC Home Act was introduced in March 2010, which requires homes to document medication incidents, disclose
them to residents, and review these incidents regularly with a view to preventing them in the future.475
65
4. Safe
4.5
Avoiding harm in long-term care
Individuals who move to a LTC home typically are unable to live independently and need supportive care.477 Physical disabilities and a
loss of cognitive functioning (memory, language and thinking abilities) may also contribute to their responding to situations with fear and
aggression, or wandering and sleeplessness. These factors put residents at high risk of unintended harm. Healthcare providers need to
do everything they can to minimize the risk of harm to residents and those who provide care.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Avoid falls.
Falls may lead to injuries, fractures or death. They can also increase the
number of emergency department visits and hospitalizations.478
Avoid new pressure ulcers.
Pressure ulcers may lead to pain and suffering, worsening infection, risk of
amputation or death.480
Ontario’s 75,000 residents in 626 LTC homes
across the province.479
Avoid physical restraints.
Physical restraints may lead to a loss of control and depression. Paradoxically, they can also increase the risk of falls, and the restraint itself may be
a safety hazard (e.g., causing asphyxiation).481
Avoid worsening behaviour (e.g., aggression
or wandering).
Worsening behaviour may cause physical or psychological harm to the
resident, other residents and staff.
Avoid bladder infections.
Bladder infections may lead to more serious infections or delirium.482
Indicator
Value
Percentage of LTC residents
with a new† pressure ulcer
(stage 2 or higher)
2.7%*
One in 36 residents will develop a new, serious pressure
ulcer over a period of three months; that’s about one
in nine residents each year. There is major room for
improvement in this indicator. Ontario can strive to
achieve a value closer to zero.
Percentage of LTC residents
whose behaviour has recently†
worsened
14%*
Percentage of LTC residents
with a recent† bladder infection
5.4%*
HQO has just started reporting these indicators and
there are no international benchmarks available yet;
however, there is very likely room for improvement. Visit
www.ohqc.ca/en/ltc_landing.php for more information.
Percentage of LTC residents
who were physically restrained
17%*
Almost one in six LTC residents were physically
restrained in the previous three months. Many LTC
homes are adopting zero-restraint policies, and some
countries have rates lower than Ontario’s (e.g. USA,
8%; Switzerland, 6%).483 Although these comparisons
should be interpreted with caution because of different
definitions of a restraint, it is reasonable to conclude
that there is room for major improvement.
Percentage of LTC residents who
had a fall in the last 30 days
14%*
Falls are common; one in seven LTC residents had a
fall in the past month. In recent years, there has been
no major change in the rate of emergency department
visits or hospitalizations as a result of falls. Substantial variation in the rate of falls across LTC homes in
Ontario suggests there is likely room for improvement. Visit www.ohqc.ca/en/ltc_landing.php for more
information.
8.8
3.0
Bottom line
20
1.8**
BETTER
Rate
Rate of falls among LTC senior
residents (aged 65+) per 100
resident years resulting in:
Emergency department
visit with fracture
Emergency department
visit without fracture
Hospitalization
Time trends & comparisons
10
0
2002/03
2009/10
Data sources:
*Resident Assessment Instrument — Minimum Data Set (RAI-MDS), FY 2009/10, calculated by Canadian Institute for Health Information. Under the system, every resident undergoes a detailed
assessment of their health at least once every three months by a staff member at the home specially trained to collect this information.
**Registered Persons Database, Ontario Health Insurance Plan Claims Database, Discharge Abstract Database, National Ambulatory Care Reporting System Database, FY 2009/10, calculated by
Institute for Clinical Evaluative Sciences.
†
From one assessment period to the next; typically, every three months.
66
4.6 Avoiding harm in home care
HOSPITAL
4.6
Avoiding harm in home care
LONG-TERM CARE
People with chronic conditions or complex needs who need healthcare services (such as nursing or rehabilitation) or personal support services over a long period of time may become long-stay home care clients. These
individuals often have physical disabilities that make them more likely to fall, injure themselves, develop skin
ulcers and experience other problems. Home care workers have an important role to play in reducing the risk
of harm.
HOME CARE
PRIMARY CARE
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Avoid falls or other injuries.
Falls and other injuries carry with them the risk of temporary or permanent
disability, or death. They may also lead to more emergency department visits
and hospitalizations.
Avoid skin ulcers.
Skin ulcers may lead to pain and suffering, worsening infection, risk of
amputation or death. They can also cause avoidable healthcare costs.
Avoid neglect or abuse.
Neglect or abuse may cause worsening physical or psychological health.
Avoid delirium (sudden confusion or
decreased alertness).
Delirium may increase the risk of injury and/or rapid deterioration resulting
in hospitalization or death.
Ontario’s 185,000
residents who receive
services through CCACs
on any given day and the
603,535508 residents
who received home
care services from
CCACs in 2009. Many
of these individuals are
long-stay clients.
Percentage of home care clients
who report that they have fallen in
the last 90 days
Value*
Time trends & comparisons
25%
Bottom line
30
BETTER
Percent
Indicator
15
One in four home care clients report falling
in the last 90 days. There has been no major improvement in the past three years.
There is room to improve.
0
Apr–Jun 07
1.6%
10
BETTER
Percent
Percentage of home care clients
with a new pressure ulcer (stage
2 to 4)
Jan–Mar 09
5
0
Apr–Jun 07
12%
Jan–Mar 09
25.0
BETTER
Percent
Percentage of home care clients
with unexplained injuries, burns
or fractures
12.5
0.0
Apr–Jun 07
1.2%*
Jan–Mar 09
10
BETTER
Percent
Percentage of home care clients
showing signs of neglect or abuse
5
0
Apr–Jun 07
Among long-stay home care clients, 1.6%
have developed a new pressure ulcer
(stage 2 to 4) identified over the previous
six months. There has been no improvement in the past three years. There is likely
room to improve.
Jan–Mar 09
Approximately one in 15 home care clients
report unexplained injuries assessed over
the past 90 days. There have been modest
improvements in the past three years.
These events tend to be unreported or undisclosed, so when they are reported it is
important to pay special attention to these
cases. There is still room to improve.
Among all home care clients, 1.2% showed
signs of neglect or abuse. There has been
no change in the last three years. These
events also tend to be underreported, so
when they are reported it is critical to pay
special attention to these cases. There is
room for improvement.
Data source:
*Resident Assessment Instrument — Home Care, FY 2009/10, calculated by Canadian Institute for Health Information. Under this system, every long-stay home care client is supposed to undergo
a detailed assessment of his or her health at least once every six months by someone specially trained to collect this information. Home care clients noted above are long-stay clients.
67
4. Safe
4.5
&
4.6
Root Cause
Ideas for improvement
Residents at high risk of adverse events are not identified
early. Early identification can ensure that those at highest risk
get more vigilant care.
Conduct risk assessments. These are typically done at admission to an LTC home
but it is important to keep these up to date. Examples include the Braden Scale and the
Pressure Ulcer Risk Scale (PURS)484 embedded in the RAI-MDS dataset now used by all
LTC homes. For falls, many risk assessment tools exist,485 and RAI-MDS also generates
Resident Assessment Protocols that can serve as risk assessments.486
Staff may be unaware of the extent of the problem.
Provide real-time feedback to providers. Ontario is already moving towards public
reporting of falls and pressure ulcers by individual LTC home. Administrators can go
further and post this information by individual unit within their homes.
Staff may forget to carry out all best practices because they
feel overwhelmed with information or distracted by other tasks.
Increase the use of checklists, reminders, standard orders or decision tools.
For example, the “turn clock tool” posted on a resident’s door reminds staff of which
position a resident should be in at certain times of the day.487
Lack of skills, training or experience. Being able to identify early
signs of ulcers, or knowing how to move a frail resident without
shearing the skin, are examples of tasks that require training.
Provide appropriate training. Consider mentorship models, where inexperienced
staff are paired with experienced ones. Verify proper technique by direct observation of staff. This may be particularly important for new or temporary staff.
Staff may feel they have not enough time to complete all
best practices.
Eliminate other activities that waste time, such as duplicate documentation, so
staff can spend more time on care at the bedside.488 The Releasing Time to Care
program, developed in the UK, guides clinical teams as they identify and streamline
processes in order to free up staff time for activities that add value for residents.489
Lack of certain equipment. Pressure relieving mattresses can
prevent ulcers. High-low beds that can drop to a low height can
reduce injuries from falls.
Develop the business case to show that these investments pay for themselves in
the long run.
Issue: Use of restraints.
Family or staff are concerned that residents will wander
if not restrained.
Provide education about the hazards of restraints. Restraints can increase the risk
of falls, pressure ulcers and asphyxiation, worsen an injury if a fall occurs and worsen
depression.490
Use alternatives to track when a potential wanderer gets up, such as bed or
door alarms to signal when someone leaves unexpectedly.
Issue: Falls.
A medical condition leads to frequent falls that are
extremely difficult to avoid.
Try using special equipment that protects the resident from harm from a fall,
such as hip protectors, helmets, non-slip footwear, keeping the height of the bed low
and having padding on the floor next to the bed in case the resident falls when getting
in or out of bed.491
Medication side effects, such as confusion and dizziness,
can lead to falls. Age can affect a drug’s effectiveness,
sensitivity and toxicity, and it may be difficult to predict potential
side effects.492 (See section 4.4.)
Avoid certain medications. Avoid drugs on the “Beers” list493, 494 and use safer substitutes. Have a medication review done to check for drug interactions (see section 4.4).
Residents have difficulty moving around. This increases the
chance of falls.
Introduce mobility aids. Residents should be fitted appropriately for aids such as
canes, walkers and scooters.496, 497 Trial equipment should also be available for
residents to test before investing in an aid. Consider ways to make their use fashionable, especially for those who may feel shame at having to use them.
Use a well-designed EMR to track medication use and reduce the use of psychoactive
drugs that can contribute to falls.495
Consider physiotherapy and rehabilitation. Exercise programs and Tai Chi are also
effective in reducing falls.498
Residents fall when rushing to get to the toilet.
68
Consider using prompted voiding techniques where residents to go the washroom
on a schedule and avoid incontinence (see section 3.4).
4.6 Avoiding harm in home care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
What is Ontario doing?
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of best practices and use of quality improvement tools. Topics of focus to date have included reducing falls and pressure ulcers, and changing
processes which waste staff time so that staff can provide more face-to-face care for the resident. The initiative is now in its second year. Almost
every Ontario LTC home is participating in the Leading Quality Program, which provides leaders with skills and tools that help them incorporate
quality improvement as a core organizational strategy.504
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in every home and screening to understand where more in-depth inspections are required. LTC homes themselves can replicate this comprehensive
assessment as they work to improve resident care.505
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and home care.506 The LHIN is also partnering with Alzheimer Society of Ontario and the Alzheimer Knowledge Exchange on the Behavioural
Support System project, which seeks to improve care for older adults with complex and responsive behaviours associated with cognitive
impairments.507
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require prolonged help to live in the community. The model of integrated home care delivery partners and aligns with other sectors to integrate
care across the healthcare continuum. In 2010, four CCACs launched early implementation sites focusing on wound care, with the aim of
improving client outcomes and increasing value for the healthcare system.512
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accountability for the provision of quality home care services through public reporting on quality measures; delivering improved health outcomes
for Ontarians through the Integrated Client Care Project (see above); enhancing fairness, transparency and communication in the competitive
procurement process; and promoting innovation and flexibility in service provision.513
69
5. Patient-centred
5.1
Patient experience in acute care hospitals and
emergency departments
In 2009 in Ontario, hospitals discharged nearly 1.1 million people from acute care beds and emergency departments (EDs) handled
5.4 million visits.514 Looking at both hospital and ED stays from the patient’s perspective can help to identify strengths and areas for
improvement in the healthcare system.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
An overall positive experience for
patients in hospitals and EDs.
When the care experience is not good, that fundamentally means the health
care system is not meeting the public’s expectations. That erodes public
confidence in the health care system and can decrease staff morale.515 Also,
people with bad past experiences with care may hesitate to seek care when
they need it.516
All Ontarians who visit an emergency department or hospital.
Patients feel they have all the information they need and are engaged in
decision-making.
When questions are not answered fully, there may be misunderstandings
about instructions on how to stay in good health.517, 518 When people do not
feel engaged in decisions, they may be less likely to adhere to recommended
drugs,519 tests or other advice.
A health care system that is easy to
navigate responds quickly to needs
and controls pain as best as possible.
Needless waits lead to lower satisfaction with care. Poor pain control leads
to unnecessary suffering and in some instances, slower rates of recovery
from illness.520, 521
Percentage of patients
who would definitely recommend their hospital
to friends and family
Hospital
ED
Value*
Time trends & comparisons
Bottom line
100
74%
58%
Percent
Indicator
50
BETTER
0
2006/07
While most patients in hospital and the ED feel they
are treated with dignity and respect, about one in
five do not. There has been no major change in the
past five years, and there is room for improvement.
100
83%
77%
Percent
Percentage of patients who
felt they were treated with
respect and dignity
Hospital
ED
2009/10
In Ontario, 74% of patients would definitely recommend the hospital in which they received care. This
is higher than the average in the USA (69%) but
leading American hospitals achieve rates of around
85%.522 Results are much lower for ED patients;
only 58% would definitely recommend their ED to
others. There has been no major change in these
indicators in the last four years, and there is obvious
room for improvement.
50
BETTER
0
2006/07
Percentage of ED patients
who said they waited too
long to see a doctor
100
68%
Percent
BETTER
50
62%
2006/07
48%
2009/10
100
BETTER
50
0
2006/07
2009/10
Data source: *NRC-Picker patient satisfaction surveys, provided by the Ontario Hospital Association, FY 2009/10.
70
About one in three hospital patients express
concern about timeliness of requests for help —
either assistance to go to the bathroom or response
to a call button. This has not improved over time.
There is room for improvement.
0
Percent
Percentage of hospital
patients who:
Got bathroom help
in time
Though the wait time
after a call button
was reasonable
2009/10
About half of ED patients reported waiting too long
to see a doctor. This has not improved in the last five
years. There is room for improvement.
5.1 Patient experience in acute care hospitals and emergency departments
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Percentage of patients
who thought the staff did
everything they could to
help control their pain
Hospital
ED
Value*
Time trends & comparisons
Nearly three in four hospital patients, but only
about one in two ED patients thought the staff did
everything they could to help control their pain. This
indicator has not improved in the last five years.
There is major room for improvement.
78%
52%
50
BETTER
0
2006/07
Percentage of patients who
received answers they could
understand when they asked
important questions to:
A nurse in hospital
A nurse in ED
A doctor in hospital
A doctor in ED
Percent of patients who
were able to understand
explanations about test
results
Hospital
ED
Bottom line
100
Percent
Indicator
2009/10
Staff in hospitals and EDs do not answer questions
or provide explanations that are understandable to
patients about one-third of the time. This has not
improved in the last four years (data not shown).
Improvement is absolutely necessary.
70%
66%
73%
70%
BETTER
0
50
100
Percent
69%
65%
BETTER
0
50
100
Percent
Data source: *NRC-Picker patient satisfaction surveys, provided by the Ontario Hospital Association, FY 2009/10.
71
5. Patient-centred
5.1
Root Cause
Ideas for improvement
Issue: Low rating of overall satisfaction in emergency department
Patients do not want long waits in
the emergency department.523
Improve patient flow in the emergency department. Address ALC bed problem and wait times for LTC
placement (see section 2.1 — Wait Times in Emergency Departments, and section 2.4 — Access to Long Term
Care and Home Care.).
Inform patients about expected wait times and reason for delays.524 Good communication with patients, particularly on arrival at the ED, helps manage expectations. Patients’ perceptions that wait times are appropriate or are shorter
than expected has been shown to be more important than the actual wait time.525
When patients don’t feel like
they’re treated with respect or
courtesy, or staff are unresponsive to their needs, they rate their
overall satisfaction lower.526, 527, 528
Improve staff and provider customer service and interpersonal skills through clinically focused customer service
training.529 Examples of ways customer service can be improved include: acknowledging people when they arrive, making eye contact, being polite despite stressful situations, showing a positive attitude, and telling people in advance what
they can expect and when.
Provide cultural competence training to help staff understand the role culture plays in interactions between health
care staff and patients and their families.530
Issue: Low rating on pain control
Pain is not adequately recognized.
Monitor pain as if it were the “fifth vital sign” 531 Mandate the routine use of visual analog scales or numeric
rating scales for assessing pain.532
The physician order for pain relief
is delayed.
Consider techniques such as patient-controlled anaesthesia, where the patient determines, within limits, how much
pain relief he or she needs.533
Physicians are afraid of drugseeking behaviour or creating
addiction among patients.534
Educate prescribers on appropriate pain management,535 so they better understand drug-seeking behaviours,
and ensure they don’t overestimate the risk of addiction.
Use standard protocols for pain control. One protocol, for example, helps providers identify different types of pain
(e.g., acute vs. chronic; somatic, visceral or neuropathic) and recommends the best drugs for each scenario.536
Issue: Patients do not get the information they require in a way they can understand
Patients may forget verbal explanations, especially if they are
stressed from their illness.
Provide written discharge instructions for all hospital and emergency department patients.537, 538 Written
discharge instructions should be simple and easy to understand and translated where necessary (see below).
Patients may not understand
instructions.
Provide patients and families with simplified instructions, using plain language539; written material could also use
pictures to reinforce instructions. Patient information tools can be standardized province-wide for common conditions.
Patients may have poor language
skills, particularly if English is not
their first language.
Have interpreter services available with interpreters who are trained in medical terminology540 for commonly
spoken languages in the community. Also have information available in multiple languages that is written in plain language.
Providers may use medical terms
that patients do not understand.
Use different media (e.g., patient videos) to explain complex information to patients.
Patients and family members
may feel uncomfortable asking
questions to clarify instructions.
This may be due to not wanting to look
foolish or uneducated, being uncomfortable with questioning authority or
sensing the provider is rushed and not
wanting to bother him/her.
72
Use the “teach-back” method to ensure that patients understand instructions. Patients are asked to repeat back
any key instructions given.541
Give patients and families a chance to ask questions. Budget enough time for questions after patients and families
have reviewed written material and have had a chance to absorb the information.542 Providers should not be rushing out
the door immediately after asking if there are any questions.
Offer reassurance that there are no “bad” questions.543
Provide Frequently Asked Question (FAQ) sheets to answer the most commonly asked questions.
5.1 Patient experience in acute care hospitals and emergency departments
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
What is Ontario doing?
t 5
IFExcellent Care for All Act, enacted in June 2010, requires every hospital to have a patient relations process to address patient experience
issues.544 The Act also states that health care organizations must conduct patient experience surveys. Most hospitals already do so voluntarily,
and those smaller hospitals who do not yet have a survey will establish one in the coming year. In future years, this requirement will spread to all
health care organizations. The Act also requires hospitals to submit annual quality improvement plans, and hospitals have been asked to include at
least one performance goal for patient experience in their plans.545
t $
BODFS$BSF0OUBSJPT0OUBSJP$BODFS1MBOoPVUMJOFTIPXBMMDBODFSQBUJFOUTJO0OUBSJPXJMMIBWFUIFJSJOUFSFTUTSFQSFTFOUFEBUB1BUJFOU
Advisory Council, a forum to advise on initiatives to improve the patient experience, as well as having access to tools to help navigate the cancer
system and manage their own journey (ocp.cancercare.on.ca).
73
5. Patient-centred
5.2
Patient experience in primary care
Primary care is often the first place Ontarians seek health care. Ensuring patients have a good experience at the primary care level is
important to maintaining a positive view of the entire health care system. A good experience, however, is more than just feeling satisfied
with care; it also means that the individual feels like care is designed around his or her needs, that communication is clear and that the
right to make one’s own decisions is respected.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Clear communication from health care
providers and easy to understand
explanations.
Having clear explanations to answers is an inherent right, and poor communication leads to poorer overall satisfaction with care. Better communication can help people understand why it is important to take certain drugs,
treatments or to change health habits, which in turn can lead to better health
outcomes.546, 547
All residents of Ontario.
Involvement in treatment decisions.
Encouraging people to manage their own chronic conditions and to feel they
are in control of their health has also been shown to result in better health
behaviours and health outcomes.548
Services that are well coordinated so
that people’s time is not wasted.
Disorganization and wasted time leads to confusion, inconvenience
for patients and families, lower overall satisfaction with care and lost
economic productivity.
Indicator
Value*
Percentage of adults who have a
regular doctor or place of care
who rate the overall quality of
medical care they received in the
past 12 months as excellent or
very good
77%
Time trends & comparisons
Bottom line
100
NEW ZEALAND
UK
ONTARIO
AUSTRALIA
US
CANADA
SWITZERLAND
FRANCE
NORWAY
NETHERLANDS
0
GERMANY
50
SWEDEN
Percent
BETTER
5.2.1 Percentage of adults who have a regular doctor or place of care who rate
74%
100
SWITZERLAND
NEW ZEALAND
AUSTRALIA
ONTARIO
US
CANADA
GERMANY
FRANCE
UK
0
NORWAY
SWEDEN
50
NETHERLANDS
BETTER
Percent
Percentage of adults who have a
regular doctor or place of care
who said this provider always
explains things in a way that is
easy to understand
Approximately three in four adults in Ontario
who have a regular doctor or place of care
rated the overall quality of the medical care
they received in the past 12 months as excellent or very good. Ontario performs relatively
well on this indicator. The province is doing
better than Quebec and many European
countries, and is on par with Western and
Atlantic Canada, the US, UK and Australia.
Only New Zealand has better results (84%).
Among adult Ontarians, 74% felt that their
regular doctor or place of care always gave
easy to understand explanations. Compared
to other countries, Ontario and Canada are in
the middle of the pack. Ontario could aspire
to match the best results achieved by Switzerland (82%) and New Zealand (80%).
5.2.2 Percentage of adults who have a regular doctor or place of care who said
66%
100
NEW ZEALAND
AUSTRALIA
US
SWITZERLAND
ONTARIO
CANADA
UK
GERMANY
FRANCE
NORWAY
0
SWEDEN
50
NETHERLANDS
BETTER
Percent
Percentage of adults who have a
regular doctor or place of care
who said this provider always tells
them about treatment options and
involves them in decisions about
the best treatment
5.2.2 Percentage of adults who have a regular doctor or place of care who said
58%
100
Data source: *Commonwealth Fund International Survey of adults, 2010.
74
NEW ZEALAND
SWITZERLAND
AUSTRALIA
US
GERMANY
CANADA
ONTARIO
UK
FRANCE
NORWAY
0
SWEDEN
50
NETHERLANDS
BETTER
Percent
Percentage of adults who have a
regular doctor or place of care
who said this provider always
spends enough time with them
Only two in three adults who have a regular
doctor or place of care said their provider
always tells them about treatment options
and involves them in decisions about the best
treatment. This is an area where there is poor
performance across the globe. Compared to
other countries, Ontario and Canada are in
the middle of the pack. Ontario could aspire
to match New Zealand’s result of 80%.
Only 58% of Ontarians felt their regular
doctor always spent enough time with them.
There are many other countries with better
performance than Ontario and Canada in this
area. Again, Ontario could aspire to match
New Zealand’s result of 80%. Having the
best performance on this and the previous
two indicators may help explain why that
country has the best satisfaction with the
care received.
5.2 Patient experience in primary care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Bottom line
100
SWITZERLAND
FRANCE
NETHERLANDS
UK
GERMANY
NORWAY
SWEDEN
0
AUSTRALIA
50
NEW ZEALAND
BETTER
US
18%
ONTARIO
Percentage of adults who
thought their time was wasted
because their medical care
was poorly organized or poorly
coordinated
Time trends & comparisons
CANADA
Value*
Percent
Indicator
Nearly one in five adults felt their time was
wasted because of poorly organized or
poorly coordinated medical care. Ontario and
Canada have some of the worst ratings in this
area. Improvement is necessary.
Data source: *Commonwealth Fund International Survey of adults, 2010.
Root Cause
Ideas for improvement
Issue: Doctors do not have time to spend with patients
Providers waste time searching for things
and doing unnecessary paperwork, resulting
in less time to spend with patients.
Use a well-designed EMR that contains all the patient information and can save time by making it
easier to access test results or other information in real-time.549, 550
Physicians may spend time doing tasks that
could be performed by other staff.
Continue to promote team-based models of care, such as Family Health Teams, where physicians
could share tasks with other providers and the practice as a whole can have more time to spend with
patients. See section 2.2 for more information.
Improve office efficiency.551 Simple steps that save minutes or seconds of each clinic visit can add
up to days or weeks of saved time over a year. See section 2.2 for more information.
Issue: Explanations not always easy to understand.
Patients may not understand questions
or instructions.
Use the “teach-back” method to ensure that patients understand instructions. Patients are
asked to repeat back any key instructions given.552
Patients and family members may feel
uncomfortable asking questions.
Give patients and families a chance to ask questions.553 Allow for questions after patients and
families have reviewed written material and have had a chance to absorb the information. See section
5.1 for more information.
Issue: Patients are not involved in decisions or treatment options
It takes time to list the options for screening
or treatment as well as the pros and cons
of each, and to identify what’s important to
patients (eg. side effects of treatment, cost of
different options, etc.).
Develop standard tools for providers to help explain options to patients, as well as the
benefits and drawbacks of each. For example, Cancer Care Ontario provides a toolkit for patients
that is designed to help them make informed decisions about their cancer screening options. The tools
include easy to read information about risk factors, methods of screening, pros and cons of various
approaches, and where to go for more information. The material is available from: www.cancercare.
on.ca/cms/one.aspx?objectId=44184&contextId=1377
Issue: Patients have a negative customer service experience
When patients don’t feel like they’re treated
with respect and courtesy, or that staff are
unresponsive to their needs, they rate their
overall satisfaction lower.554, 555
Improve staff and provider customer service and interpersonal skills through programs such
as clinically focused customer service and communication training.556 Examples of ways customer
service can be improved include: acknowledging people when they arrive, making eye contact, being
polite despite stressful situations, showing a positive attitude, and telling people in advance what they
can expect and when.
What is Ontario doing?
t5IFNJOJTUSZIBTDPNNJTTJPOFEBmWFZFBSMPOHJUVEJOBMTUVEZUPFWBMVBUFUIFFGGFDUJWFOFTTPG'BNJMZ)FBMUI5FBNTJODMVEJOHQBUJFOUFYQFSJFODFBOE
patient satisfaction.557
75
6. Efficient
6.1
Cost of service delivery
It is important for hospitals and community agencies to operate efficiently by eliminating waste or using the most effective treatment
options, so they can offer the best patient care in exchange for the lowest cost. Part of any organization’s plan for efficiency must be to
manage finances well and avoid incurring deficits or running into circumstances where it becomes hard to meet commitments to pay bills
when they are due. Provincial data on cost effectiveness is poor, and it is difficult to measure inefficiencies across the system. Thus, better
data capture is necessary (see section on data advocacy).
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Hospitals with sufficient revenue to
cover their costs.
When hospitals spend more than they receive, they have to borrow money —
and when that happens, taxpayer dollars go towards interest charges instead
of towards purchasing equipment or providing patient care.
Ontario’s taxpayers, who want to
know their tax dollars are being
wisely managed.
Hospitals able to pay bills on time with
liquid resources (i.e., cash).
Again, when hospitals have to borrow to pay bills, taxpayer dollars go
towards interest instead of towards needed goods and services.
Hospital expenses minimized as much
as possible, without compromising
high-quality patient care.
When hospitals are compared and have significantly different costs to treat
the same type of patient, it may mean that less efficient hospitals are using
resources inappropriately.
Current ratio†† of hospitals
(ability to pay bills without
having to borrow):
Province
Small community
Large community
Teaching
Chronic/rehabilitation
Time trends & comparisons
Across the province, almost 30% of hospitals
reported a deficit in FY 2009/10. The number
of hospitals reporting a deficit has decreased
by a third in the last year. There is still opportunity to avoid deficits.
27%
28%
36%
14%
20%
30
BETTER
0
2004/05
0.81
1.7
0.7
0.81
1.1
2009/10
3
IDEAL
2
2
1
1
0
2004/05
2009/10
7,000
Cost
Cost per weighted case†††
in hospitals:
Small community
Large community
Teaching
3,500
0
2005/06
2009/10
The ideal current ratio of hospitals in Ontario
should be between 1 and 2. Small community hospitals previously had a current ratio
which was too high (i.e. more cash on hand
then necessary) but this has decreased over
the past five years and is now in the desirable range. Teaching hospitals had too low
a ratio but this has increased in the past five
years, although is still short of the ideal range.
Chronic/rehabilitation hospitals have consistently been in the desired range. For large
community hospitals, the results have gotten
worse over the last five years. The bottom line
is that there is still room to improve, particularly for large and teaching hospitals.
Even after adjusting for the complexity of
cases, the actual cost for a community
hospital stay has increased by over 20% in
the last four years (more than the rate of inflation). Teaching hospitals, however, reported
a slower increase of 13% over the same time
period. There is room to improve.
The cost for a complex continuing care
patient’s hospital stay per day in small community hospitals is close to $200 more than in
other hospitals. Over the last four years, the
actual cost for a chronic care hospital stay
has increased more than inflation.
800
Cost
Cost per weighted patient day††† in
complex continuing care hospitals:
Small community
Large community
Teaching
Chronic/rehabilitation
Bottom line
60
Percent
Percentage of hospitals running
a deficit:†
Province
Small community
Large community
Teaching
Chronic/rehabilitation
Value*
Ratio
Indicator
400
0
2005/06
2009/10
Data source: *MOHLTC, FY 2009/10.
†
Technically, a “negative budget position.” Based on the Ontario Hospital Service Accountability Agreements. (Total Revenues — Facility Grant Amortization) — (Total Expenses — Facility Amortization).
††
Based on the Ontario Hospital Service Accountability Agreements. The numerator includes Current Assets plus debit Current Liability Balances, excluding Deferred Revenues. In plain language, this is
the amount of cash or other assets that can be converted quickly into cash. The denominator includes Current Liabilities excluding Deferred Revenues plus credit Current Assets, except Current Asset
Contra Accounts. In plain language, this is the amount of short-term debts.
†††
Resources Utilization Groups III grouping methodology. The in-patient case weight information enables comparisons among hospitals regardless of differences in the severity of illness and
complexity of cases served by these facilities. Costs were not adjusted for inflation.
76
6.1 Cost of service delivery
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for improvement
Issue: Overall demand for hospital services is increasing beyond what hospitals can provide with current budgets.558
Avoidable demand on hospitals.
Improve chronic disease management in the community (see section 3.2). Acute care in-patient costs
for conditions related to chronic disease are high, with acute myocardial infarctions (AMIs) and cerebrovascular diseases representing the two most expensive medical conditions in Canada.559 Studies have shown that
improving the care of people with chronic diseases before they require hospitalization can decrease associated hospital costs.560, 561, 562, 563, 564
Improve access to long-term care (LTC) and home care, and ensure safe conditions and
appropriate care to prevent avoidable hospitalizations (see sections 2.4, 4.5 and 4.6).
Improve access to primary care (see section 2.2). Studies have shown that better access to primary care
results in fewer visits to the emergency department and admissions to hospital.565, 566
Coordinate among health services, such as primary care, specialists and hospitals, to improve health
outcomes and use of resources.567
Avoidable hospital readmissions.
Ensure patients leave the hospital on the right medications (see section 3.1) and have all the information they
need to function at home. Consider specialized out-patient clinics (e.g., for congestive heart failure568, 569, 570)
or similar services that have been shown to reduce readmissions (see section 3.3).
Patients are occupying hospital beds unnecessarily. These patients do not require the
intensity of resources or degree of services
provided in that setting, and could be better
served elsewhere.571
Ensure that patients are being cared for in the most appropriate place
(see sections 2.4 and 6.2).
Hospital services such as diagnostic
screening and surgical procedures may be
used inappropriately.
Eliminate unnecessary tests or procedures, such as repeat tests or pre-operative tests for minor
procedures (see section 6.3). A study of Ontario doctors revealed that use of CT and MRI screening may
not always be for appropriate reasons.572 Consider using appropriateness criteria for CT and MRI scans,573
as well as for procedures such as hip and knee replacements574, 575, 576 and cataract surgery.577
Unnecessary duplication of tests due to
fragmentation of care. The results of tests
ordered in primary care are often not available
to hospital staff.
Implement integrated electronic health records (EHRs), which provide convenient access to test results
ordered by other providers and in different settings.578 This could help reduce unnecessary repeat tests that
are done because test results from elsewhere are unavailable.
Avoidable complications of hospital care
waste resources. Hospital-acquired infections579
and other complications that develop while in
hospital increase length of stay and overall costs.
Work on areas where there is a strong business case for quality.580 A strong business case can be
made when investments in improving quality are more than offset by reductions in cost for the same organization within a reasonable period of time. Business cases are well established for areas such as ventilatorassociated pneumonia581 and pressure ulcer prevention.582
Inefficient processes within the hospital
waste time and resources.
Improve use of staff time and reduce redundancies (see section 2.1).583
Improve efficiency of discharge processes.584 Consider options for improving the discharge
rate, such as setting target discharge dates, staggering discharge times during the day, and clearly
communicating plans with the patient and family so they can be ready for discharge. Utilization management
software may help guide decisions on when it is safe to discharge patients. (See section 8.1 for information
on improving communication and collaboration between hospitals and those who will be providing postdischarge care, and section 2.1 for information on improving care coordination to ensure that patients are
moved to the right place as soon as possible so they are not occupying beds unnecessarily.)
What is Ontario doing?
t 5
IF.0)-5$JTXPSLJOHPOBNBKPSSFGPSNPGIPXIPTQJUBMTBSFGVOEFE$VSSFOUMZIPTQJUBMTBSFGVOEFENPTUMZUISPVHImYFEHMPCBMCVEHFUTXIJDIBSF
largely determined by historical factors. In many cases, this funding does not reflect the population served or the types of patients cared for. Hence, a
hospital in a high growth area may find it difficult to provide services to the expanded population if its global budget does not increase to reflect the
greater demand. The MOHLTC’s Patient-Based Payment strategy585 aims to use a “money follows the patient” approach which links hospitals’ funding
to the level of services and quality of care they deliver. The strategy draws on the Health-based Allocation Model (HBAM), which determines the
expected costs of delivering care, taking into account differences across communities in age, socioeconomic status and existing health conditions.
77
6. Efficient
6.2
Right service in the right place
Individuals should be cared for in settings that best meet their needs, rather than settings that are more costly and not designed to
accommodate them. The most pressing example is the Alternate Level of Care (ALC) patient.586 These individuals (often, frail, elderly with
multiple chronic conditions) may enter hospital with an acute problem needing immediate attention and then recover but still have difficulty
functioning independently. The doctor may not discharge the patient if she is concerned that he cannot get enough home care to live safely
at home. The patient may then be referred to a long-term care (LTC) home, but must wait in the hospital, often for weeks or months as an
ALC patient, until a bed becomes available (see section 2.4).
Another example is people who are placed into a LTC home who could have been served elsewhere. Individuals who do may not need all the
services that a LTC home provides may still end up being referred there because of lack of alternatives. The MAPLe (Method for Assigning
Priority Levels) algorithm allows planners to identify these individuals.587
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Patients who no longer need hospital
services are discharged to a more
appropriate setting.
The cost of caring for an ALC patient in hospital is higher than caring for the
same person in a more appropriate setting, such as an LTC home. Furthermore, LTC staff are specially trained to take care of people who are frail and
need many support services; thus, the resident can be provided with more
appropriate care. Another consequence of the ALC challenge is that beds
occupied by ALC patients are not available to patients waiting to be admitted
from the emergency department, leading to long wait times. Elective surgeries
could be delayed as well. Finally, when older people are hospitalized for acute
illnesses, they may lose their independence and are at high risk for discharge
to LTC homes.588, 589, 590, 591
Ontario’s 2,800 acute care hospital patients and 1,900 patients
in other hospital settings (e.g.
mental health, rehabilitation facilities) who, on any given day, are
designated as ALC patients.592
People whose needs can be met
through alternatives to LTC (e.g.,
home care or supportive housing) can
remain living in the community — with
LTC beds reserved for those who truly
need them.
When less expensive alternatives of the same or better quality are available but
not used, healthcare resources are wasted.
Ontario’s 170,000593 long-stay
home care clients who may need
more care in the near future.
Indicator
Value
Percentage of patient bed days
in acute care hospitals that are
designated as ALC
16%*
Time trends & comparisons
Bottom line
Percent
18
9
BETTER
0
2008/09
2006/07
Percentage of hospital beds
that are ALC within a LHIN
Relationship between ALC bed
days and LTC wait times
One in six acute care hospital beds in
Ontario are filled with patients who could
best be cared for elsewhere. This problem worsened from FY 2006/07 to FY
2008/09 and has not improved in the
last year, FY 2009/10, despite huge
investments from the Aging at Home
strategy (see next page). This is one of
the most urgent priorities for improvement in Ontario.
There is a strong relationship† between
wait times for LTC placement for hospital
patients and the percentage of ALC bed
days within a LHIN. Every increase of
about 5.6 days in wait times leads to a
1 % increase in the percentage of beds
designated as ALC within that LHIN.
30
25
20
15
10
5
0
0
20
40
60
80
100
120
140
Median wait times (days) to LTC placement for hospital patients within a LHIN
22%**
80
Percent
Percentage of people placed into
an LTC home who do not have
high or very high needs for LTC
services and could potentially be
cared for elsewhere
40
BETTER
0
Apr-Jun 08
Jan-Mar 10
Over one in five people placed in LTC homes
do not have high or very high care needs.
These people could potentially be cared for
in other settings in the community (e.g., with
more home care or in supportive housing
arrangements). This indicator has improved
in the last two years; however, there is still
room for improvement.
Data sources:
*Discharge Abstract Database (DAD), Canadian Institute for Health Information (CIHI), April 2006 to March 2010, provided by Cancer Care Ontario.
**Based on the MAPLe score.587 Client Profile Database, MOHLTC, January to March 2010, provided by the Toronto Central CCAC.
†
R-squared = 0.86, indicating a strong relationship.
78
6.2 Right service in the right place
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for improvement
People’s care needs are
inadequately assessed.
Identify early those at risk of being hospitalized and subsequently becoming LTC patients — for
example, frail individuals or those with dementia living in the community with unmet needs.594, 595, 596 Identifying
these people early and providing them with adequate home care support may help to slow down the decline in their
health and make it easier for them to go back home should they ever need to be hospitalized.
One program in the Mississauga Halton LHIN aims to ensure that every person aged 75 and over who comes to
an emergency department has a home care assessment.597 Use of the interRAI Community Health Assessment
by community support agencies can help to identify more objective levels of risk in this population.
Patients may decondition while in
hospital. Being in a foreign environment may lead some patients to
lose their function.
Started in 2007, transitional care programs give former hospital patients a period of reconditioning in a
retirement home before they return home.598
The Champlain LHIN has piloted a 22-bed program that provides alternative care to medically stable hospital
patients waiting for an LTC bed. This has reduced bottlenecks that lead to emergency room crowding and
cancelled surgeries.599
Patients may benefit from acute, in-hospital rehabilitation and intensive, long-term, follow-up rehabilitation to improve the chances that they will recover their pre-hospitalization abilities.600
People are prematurely labelled as
needing LTC, or go into LTC before
they need it.
Use objective criteria to help determine who truly needs LTC. Carefully screen individuals’ healthcare
needs to ensure that only those with heavy needs actually get on the waiting list. This may help to address
situations where people who fear long waits get themselves on the list “just in case.” Tools such as the MAPLe
score601 can help care planners decide whether an individual’s needs are heavy enough that they should be put
on the list.
Employ the Home First Approach and send patients home from the hospital rather than directly to
LTC602 (see section 2.4).
Alternatives to LTC are not being
fully utilized or supported.
Ensure there are sufficient alternatives to LTC homes, such as assisted living homes or supportive
housing,603 where frail individuals can access some degree of ongoing care if their needs are less than what an
LTC home would provide (see section 2.4).
Alberta has developed a Continuing Care System that includes supportive housing in its strategy.604, 605 In 2009,
HQO reported on the region around Lethbridge, Alberta, where this strategy helped keep the waiting list for LTC at
only 29 days despite using one-third fewer LTC beds than Ontario. This region provides publicly funded options for
assisted living and supportive housing that allow people to live in a home-like environment with 24-hour assistance
when needed if they require less care than that provided by LTC but more than that offered by home care.606
Limited availability of home care.
Consider increases in home care availability. In the past, there were caps on hours of care for home
care clients; these have recently been extended. This change may allow some clients to avoid being put on
a waiting list for LTC. However, for people with heavier needs, other options such as assisted living may be
more cost-effective than home care.
Avoidable demand due to poorly
controlled conditions that could
have been addressed in a primary
care setting before they escalated.
Improve primary care services. Improve access to primary care (see section 2.2), including after-hours
primary care and management of chronic diseases (see section 3.2) so patients are less likely to require
hospitalization.
What is Ontario doing?
t0OUBSJPIBTJOWFTUFEPWFSNJMMJPOPWFSUIFQBTUUISFFZFBSTJOUIF"HJOHBU)PNFTUSBUFHZ607 which recognizes the need to provide access to
a continuum of services for seniors and their caregivers, help seniors continue to lead healthy and independent lives, and assist those who wish to
remain at home to live safely and with dignity and independence. The strategy was expected to relieve pressures on hospitals and LTC homes by
helping to find more appropriate settings for patients ready for discharge from hospital.608 It was also intended to help seniors avoid unnecessary
visits to the hospital, reduce emergency department wait times609 and ultimately reduce ALC. However, the ALC situation has not yet improved, and
it is important to evaluate the impact of this strategy (please see the data advocacy section 1.12).
79
6. Efficient
6.3
Avoidable emergency department visits
Many people end up in an emergency department (ED) because they are not familiar with other available choices. While EDs are intended to
handle serious illnesses and injuries that require fast, highly skilled care, people often go to an ED for minor problems that could be treated
in a doctor’s office or after-hours clinic. This section examines the rate of avoidable ED visits in Ontario.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
People with non-urgent conditions
(e.g., colds, sore throats, ear aches,
bladder infections or needing prescription
renewals) should be treated outside the ED
in doctor’s offices, after-hours clinics or
urgent care centres.
Beyond the high cost of treatment in an ED, patients miss out on the
benefits they receive when they are treated by a primary care doctor
who knows them and is familiar with their medical history.
Ontario’s one in five residents
who visit an ED each year610
(there are approximately
5.5 million ED visits every
year in major cities within
Ontario611).
Early identification and treatment of long-term
care (LTC) residents’ worsening medical
conditions (e.g., diabetes, pneumonia and
congestive heart failure), so that their condition does not deteriorate to the point that
they need to be sent to an ED.
Without early identification and treatment, LTC residents may experience
an avoidable ED visit612 and suffer harm because of an avoidable worsening of their medical conditions.613
Ontario’s 75,000 residents
in 626 LTC homes across
the province.614
Treatment within an LTC home for residents
with non-urgent, low acuity conditions, so it
doesn’t become necessary to send them to
an ED.†
An LTC resident who experiences an avoidable ED visit is exposed to an
unfamiliar place,615 which may be distressing if he or she has dementia.616
Other negative consequences include inconvenience for the resident
(with long lengths of stay in the ED) and expense for the province (LTC
residents usually arrive in the ED by ambulance).
Time trends & comparisons
21**
FRANCE
GERMANY
NORWAY
NEW ZEALAND
AUSTRALIA
SWEDEN
UK
NETHERLANDS
CANADA
ONTARIO
50
SWITZERLAND
100
0
BETTER
Almost one in two Ontarians felt they could
have been treated by their primary care
provider if care had been available the last
time they went to the hospital or ED. Ontario
is tied with the rest of Canada, the US and
Switzerland as having the worst results on this
indicator compared with eight other countries.
Hospital and ED resources could be better
utilized if individuals were seen in more
appropriate care settings.
Potentially avoidable ED visits are common
among LTC residents. There has been no
major change in the past seven years in
this area. There is likely room for major
improvement.
40
Rate
Rate of potentially avoidable
ED visits per 100 LTC residents
per year
Bottom line
48%*
US
Percentage of people in Ontario
who thought they could have been
treated by the doctor or staff at
the place where they usually get
medical care if care had been available the last time they went to the
hospital or ED
Value
Percent
Indicator
20
BETTER
0
2002/03
7.8***
40
Rate
Rate of low acuity ED visits per 100
LTC residents per year
2009/10
20
BETTER
Over the past seven years, there has been
continuous improvement in the rate of low
acuity ED visits by LTC residents. This is good
news, but there may still be room for further
improvement.
0
2002/03
2008/09
Data sources:
*Commonwealth Fund International Survey of Adults, 2010.
**National Ambulatory Care Reporting System Database (NACRS) and Ontario Health Insurance Plan (OHIP), FY 2009/10, calculated by Institute for Clinical Evaluative Sciences (ICES).
***Registered Persons Database, OHIP, Discharge Abstract Database, NACRS, FY 2009/10, calculated by ICES
†
Non-urgent visits are defined as those assessed according to the Canadian Triage and Acuity Scale (CTAS) as level 4 or 5, where the person was subsequently sent back to the LTC home.
80
6.3 Avoidable emergency department visits
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for improvement
Issue: Non-urgent ED visits.
People do not understand the purpose
of the ED or may be unaware of alternatives
to the ED, such as after-hours or walk-in
clinics.617
Consider public education and awareness campaigns about the appropriate use of the ED. Also
consider further promotion of the use of the Telehealth Ontario toll-free number, which gives Ontarians the
opportunity to talk with a nurse to help assess when to go to the ED.618,619 Telephone nursing triage systems
such as Telehealth Ontario have been found to reduce inappropriate use of EDs.620
Poor access to primary care. People
will use the ED if they don’t have a primary
healthcare provider, cannot get a timely
appointment with their provider, or afterhours service is not available.621, 622
Improve access to primary care. Consider better organization of primary care offices and management of
patient appointments to reduce wait times, and provide after-hours service (see section 2.2).
The frail elderly and people who have
poorly controlled chronic diseases are
prone to health crises. Patients may not
follow healthcare providers’ recommendations
for self-management or receive all evidencebased treatments from their providers.
Work towards better management of patients with chronic diseases. Patients with chronic diseases need
to be more engaged in the care and management of their conditions. Primary care of these patients should be
carefully managed to avoid crises requiring immediate attention (see section 3.2).
Patients of family physicians who practice within groups or teams that provide after-hours clinics and access to
on-call advice from a clinician are less likely to go to an ED.623 Establishment of family health teams in Peterborough resulted in 15,000 fewer ED visits.624
Issue: Avoidable ED visits by LTC residents.
Staff at LTC homes may be uncomfortable handling relatively minor emergencies and may have a low threshold for
sending recently discharged patients
back to hospital at the first sign of any
complication or regression.
Increase training of staff at LTC homes so they know how to handle and assess minor emergencies.
Nurse practitioners in LTC homes can provide clinical support for both patients and staff to reduce unnecessary
use of EDs.
An on-call primary care provider
is not available to assess the
resident’s situation.
Consider redesigning on-call schedules — for example, sharing an on-call physician, nurse practitioner or
physician assistant between LTC homes in close proximity to each other.
A lack of diagnostic equipment in
the LTC home (e.g., X-ray machines,
urgent lab services) requires residents
to go to hospitals.
Family members may exert pressure
to send a resident to an ED for assessment. This may occur if the family does
not have confidence in the staff’s ability to
handle the situation.
Consider use of telemedicine to access expert advice with a video link.625
Consider using nurse practitioners and registered nurses either in the on-call schedule or to mentor
other staff. For example, the Toronto Western Hospital created a Mobile Emergency Nursing Team of registered
nurses who take acute care nursing expertise directly to the bedside of LTC home residents to reduce ED visits.
In the first year of operation, the team was able to care for 78% of residents who would otherwise have been
transferred to the ED for assessment and care.626 Similar programs exist in the Central East LHIN627 and Central
West LHIN.
Reassure families that strategies above have been taken to ensure proper assessment within the
home. Also inform families of potential risks of ED transfers (e.g., hospital-acquired infection, worsening
confusion, wandering, falls in an unfamiliar environment).
What is Ontario doing?
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MBVODIFEJOQSPWJEFTJOGPSNBUJPOBCPVUEJGGFSFOUXBZTUPBDDFTT
healthcare (e.g., walk-in clinics, urgent care centres and family health teams).628 In addition, public awareness campaigns continue to encourage use of
Telehealth Ontario’s toll-free services, which advise whether an ED visit is necessary.629
t*O':GVOEJOHGPSOFXDPNNVOJUZIFBMUIDFOUSFT$)$T
XJMMIFMQQSPWJEFQIZTJDJBOTFSWJDFTTPQBUJFOUTDBOBWPJEVOOFDFTTBSZ&%WJTJUT630
t5IFNJMMJPO(FSJBUSJD"TTFTTNFOUBOE*OUFSWFOUJPO/FUXPSL("*/
QSPHSBNJTFTUBCMJTIJOHGPVSVSHFOUFNFSHFOUDMJOJDTGPSTFOJPSTJOUIF$FOUSBM&BTU-)*/T
largest community hospitals. Emergency and community-based physicians can refer patients to these clinics, staffed by a highly trained geriatric team and
supported by a geriatrician, for specialized assessment and intervention. If required, patients are admitted to an in-patient unit specially designed to care for frail
seniors and/or linked to community support services. The clinics are expected to see nearly 8,000 visits annually after all four open by April 2011.631
t1IZTJDJBOTQBSUJDJQBUJOHJOFMJHJCMFQSJNBSZIFBMUIDBSFNPEFMTBSFPGGFSJOHi"GUFS)PVSTwBOEi5FMFQIPOF)FBMUI"EWJTPSZ4FSWJDFw5)"4
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patients to improve access to family health care and divert non-emergency visits from hospital EDs.632
81
6. Efficient
6.4
Avoiding unnecessary drugs and tests
In healthcare, there are many instances where the choice to administer drugs or tests adds no value and should not be made, or where it’s
possible to substitute a less expensive alternative that is equally effective. This section looks closely at two examples: unnecessary
pre-operative testing for cataract surgery633 and using more expensive alternatives to thiazides to treat high blood pressure.634
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
637
The elimination of tests that do not
improve patient safety, including electrocardiograms (ECGs) and chest X-rays
before minor procedures (e.g., cataract
surgery).635, 636
Unnecessary tests waste time and money. In the case of chest X-rays,
patients are also exposed to extra radiation.
Ontario’s 13 million residents,
including the approximate
140,000 people who receive
cataract surgery each year.638
The use of lower-cost drugs if they are
just as effective as newer, more expensive ones — such as thiazides, which are
a type of diuretic or “water pill.”†639
Using more expensive medications, when cheaper, equally effective ones
are available, wastes money.640
Ontario’s residents who are newly
diagnosed with uncomplicated
hypertension, including more
than 14,000 seniors last year.641
Indicator
Time trends & comparisons
Bottom line
29*
100
Rate
Rate of pre-operative ECG testing
per 100 cataract surgeries
Value
50
BETTER
0
3.9*
2009/10
2002/03
2009/10
100
Rate
Rate of pre-operative chest X-ray
testing per 100 cataract surgeries
2002/03
About three in 10 patients who have
undergone cataract surgery received an
unnecessary ECG test. Furthermore, about
one in 25 individuals also had a chest X-ray.
Ontario has done well in reducing the use of
these wasteful tests over the last seven years.
Since the last time point, these services have
been delisted; however, there are many other
areas to look at in the future.
50
BETTER
0
17%**
100
Percent
Percentage of elderly patients with
uncomplicated hypertension† treated
with diuretics such as thiazides as a
first-line treatment within one year of
diagnosis
50
BETTER
Just one in six elderly patients with uncomplicated hypertension receive treatment with
diuretics such as thiazides within one year
of diagnosis — and this indicator has gotten
steadily worse over the past five years. There
is room for improvement.
0
2002/03
2008/09
Data sources:
*Registered Persons Database (RPD), Discharge Abstract Database (DAD), Same Day Surgery Database, Ontario Health Insurance Plan (OHIP) Claims Database, FY 2009/10, calculated by Institute for
Clinical Evaluative Sciences (ICES).
**RPD, Ontario Diabetes Database, Ontario Drug Benefits Database, DAD, OHIP Claims Database, FY 2009/10, calculated by ICES.
†
Uncomplicated high blood pressure is defined as high blood pressure where the patient does not have diabetes, kidney failure, coronary artery disease, stroke, migraine or liver failure, where other
drugs for high blood pressure would be more appropriate. Guidelines suggest that in such cases the drug of choice is a thiazide.
82
6.4 Avoiding unnecessary drugs and tests
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for improvement
Providers may be unaware of or may
not remember all the details of practice
guidelines or appropriateness criteria,
especially if the criteria are complex with
multiple recommendations and exceptions
to recommendations.
Organize information in appropriateness criteria into decision trees or algorithms. Appropriateness
criteria often identify many different clinical scenarios and the tests which are and are not appropriate in each
situation.642, 643 These criteria are often not followed,644 however, and part of the reason may be that the way they
are designed makes it hard to quickly look up the right clinical scenario. A decision-tree format can help the user
find the right recommendation with greater ease.
An outdated practice may persist
because of force of habit.
For certain tests that should be ordered not routinely but only in exceptional circumstances, eliminate
tick-box options in order forms or standard order sets. When this was done for urea and Erythrocyte Sedimentation Rate (ESR) testing in Ontario in the 1990s, use of these tests decreased 58%.647
Providers may not know whether
or not they are following guidelines
for appropriate use, and may not realize
there is a problem.
Regularly measure rates of appropriate use of tests or other services to give providers and organizations
an idea of how they are performing and to help them identify areas for improvement.648
Providers may be sceptical of the validity
of practice guidelines or appropriateness criteria.
Opinion leaders can help encourage the adoption of evidence. Identified by their peers, these “educational
influentials” operate within their communities to teach and facilitate change.649, 650
There is no incentive to stop ordering
unnecessary tests or services.
Do not pay for services when they do not meet criteria for appropriateness. See “What is Ontario Doing?’
below for examples. When policies like this are enacted, there are usually mechanisms to allow payment in exceptional circumstances.
Healthcare providers may be influenced
by sales representatives from drug
companies.651 Healthcare providers may
lack time to critically appraise the literature
regarding more expensive alternatives and
defer to information provided by sales representatives from drug companies. Often,
marketing campaigns promote more expensive drugs over older, less expensive drugs.
Programs involving trained academic detailers (often pharmacists or nurses), who visit primary care offices
to promote evidence-based drug prescribing practices based on objective appraisal of the literature, have successfully changed prescribing practices.652, 653, 654, 655
Making change is difficult in a complex
health care system, where all of the root
causes above reinforce each other.
Multifaceted interventions are the most likely to change provider behaviour. For example, a project
by the Ontario Guidelines Advisory Committee and the Institute for Clinical Evaluative Sciences reduced the use
of pre-operative chest radiography for low-risk surgeries in Ontario hospitals by 13%, and the largest changes
were observed in institutions with the highest rates of chest radiography use pre-intervention.656 This intervention
involved workshops to disseminate information, the development of a pre-operative testing checklist, and
identification of opinion leaders, who were consulted about barriers to adoption and trained to facilitate change.
Hospital-specific feedback on pre-operative testing rates was also provided to all Ontario hospitals.
Embed decision support algorithms into the test ordering process and issue prompts or request confirmation if appropriateness is rated low. Such algorithms ask the health care provider questions about the
patient’s symptoms or conditions and match that information against appropriateness criteria. If the test is likely
inappropriate, the algorithm may issue a warning, suggest alternatives to the test, or request confirmation that the
test is still needed. Such algorithms work best with electronic ordering systems. Massachusetts General Hospital,
using such a system, reduced the number of likely unnecessary CT scans by more than half.645 The Medicare
program in the US is currently running broad pilot tests of these systems.646
What is Ontario doing?
t0O+VOFUIFExcellent Care for All Act was passed into law. Health Quality Ontario, under the legislation, will make recommendations on possible
changes to the way health care is covered and paid for to ensure that it is consistent with the best clinical evidence.657
t&GGFDUJWF+VMZDIBOHFTXFSFNBEFUPUIF0)*1GFFTDIFEVMFUIBUTUPQQFEQBZNFOUGPSDFSUBJOTFSWJDFTKVEHFEUPCFVOOFDFTTBSZJODMVEJOH
ECGs and chest X-rays before cataract surgery (unless there is some other reason to do them) and sleep studies that are repeated too soon after a
previous study.658
83
7. Appropriately resourced
7.1
Overall spending and value for money
Healthcare is a large and complex system that consumes significant financial resources. Calculating healthcare spending as a percentage
of provincial gross domestic product (the total value of all the goods and services Ontario produces) is one way to quantify Ontario’s
investment. However, a higher or lower number doesn’t necessarily mean the province has found the right or best level of healthcare
spending. Paying more might be a good decision if Ontarians could be confident they were buying higher-quality healthcare. At the same
time, healthcare spending must be balanced against spending in other areas, such as education, social services and infrastructure.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Good value, including high-quality healthcare
services, in exchange for their taxpayer dollars.
When Ontarians overpay for healthcare, they have less money to spend on
other high-priority areas.
Ontario’s 13 million
residents.
Total healthcare spending
as a percentage of gross
domestic product (GDP)†
Ontario
Canada
Value*
Time trends & comparisons
14
Percent
Indicator
12.2%
11.7%
7
0
2000
2010
67%
33%
NORWAY
AUSTRALIA
UK
ITALY
SWEDEN
NEW ZEALAND
NETHERLANDS
BELGIUM
CANADA
SWITZERLAND
50
0
1981
Private spending
Total healthcare expenditures in Ontario per capita
Total spending
Public spending
Private spending
$ billions
Public spending
billion
billion
billion
In 2010, Ontario’s total spending on healthcare was projected to be $75 billion — a major increase of 91% since
2000. Healthcare expenditures have risen by an average
of 9.1% per year since 2000.
40
0
1975
2010
Ontario’s per capita spending on healthcare was projected to be $5,641 in 2010 — an increase of 69% since
2000. Since 2000, per capita healthcare expenditures
have risen by an average of 6.9% per year.
6,000
In 2008, Canada placed fifth in spending when
compared to other Organisation for Economic
Co-operation and Development (OECD) countries in
total healthcare spending.** Ontario appears to spend
more of its GDP on healthcare than all countries
except the United States and France.
2010
80
$
Total healthcare expenditures in Ontario
Total spending
In 2010, Ontario spent 12.2% of its total GDP on healthcare, a 38% increase from 2000. Historically, Ontario
spent less of its GDP on healthcare compared to Canada
as a whole — but now it spends more. The peak seen in
2009 may not be a reflection of increased healthcare
spending, but rather the result of a contraction in overall
economic activity. Especially during difficult economic
times, it is a challenge to sustain spending increases.
Currently, two-thirds of healthcare spending comes from
public dollars. This proportion has been stable since
1996. There was a significant shift towards more private
spending from 1992 to 1996; prior to that time period,
almost three-quarters of health expenditures were
publicly funded.
100
Percent
Health Expenditure as a
Proportion of Total Health
Expenditure
Public spending
Private spending
FRANCE
0
US
8
GERMANY
Percent
16
Bottom line
3,000
0
1975
2010
Data sources:
*
Canadian Institute for Health Information, 2010.659 Data for calendar year 2009 and 2010 are forecasted.
Organisation for Economic Co-operation and Development, 2008. Note the OECD calculation is different, giving rise to slightly lower numbers.660
**
84
7.1 Overall spending and value for money
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Expenditures versus value for money
Ontario spends more on healthcare than many other industrialized countries — but is the province getting added value for its extra investment? Unfortunately, as the table below indicates, Ontario gets lower scores on several of the selected key quality indicators than eight countries that spend less. When
researchers661 compared Canada’s performance to the performance of European countries across a much more detailed list of indicators, they observed
that treatment quality in Canada was on par with most European countries, but wait times and patients’ rights scored lower. They ranked Canada in last
place among 32 nations on the “Bang-for-the-Buck” index.
Indicator
Total healthcare expenditure as
a percentage of GDP, 2008*
Ontario
UK
Netherlands Norway
Sweden
Australia
New
Zealand
USA
France
11.2%†
8.7%††
9.9%††
8.5%††
9.4%
8.5%†††
9.9%
16%
11%
Total percentage of public
health expenditure, 2008*
68%
83%
n/a
84%††
82%
n/a
80%
47%
78%
Percentage of family doctors using electronic medical
records (EMRs), 2009**
43%
96%
99%
97%
94%
95%
97%
46%
68%
Percentage of adults able to
see a doctor the same or next
day, 2010***
48%
69%
69%
42%
48%
65%
77%
54%
60%
Percentage of adults who
waited four weeks or more to
see a specialist, 2010***
51%
28%
30%
48%
45%
46%
38%
17%
47%
Percentage of adults who rate
the overall quality of medical
care they received in the past
12 months from their regular
doctor’s practice or clinic as
excellent or very good, 2010***
77%
79%
54%
59%
43%
76%
84%
74%
67%
Mammography screening
rates, 2008§
73%
75%
85%
98%
84%
n/a
n/a
n/a
78%
Life expectancy (age), 2007§§
81
80
80
81
81
82
81††
78
81††
Infant mortality rate per
1,000, 2007§§§
5.2
4.8
4.1
3.1
2.5
4.2
4.8
n/a
3.8
Data sources:
*Organisation for Economic Co-operation and Development, 2010.662
**Commonwealth Fund International Survey of Physician Practices, 2009.
***Commonwealth Fund International Survey of Adults, 2010.
§
EuroHealth Consumer Index 2008;663 Ontario rates from Canadian Community Health Survey, 2008.
§§
World Health Organization;664 Ontario data from Statistics Canada, Canadian Vital Statistics, Death Database and Demography Division (population estimates), CANSIM table 102-4307, Ontario result
is a three-year average of 2005-2007.
§§§
Organisation for Economic Co-operation and Development, 2010, Ontario numbers from Statistics Canada, CANSIM, table 102-0504 and Catalogue no. 84F0211X.
†
Estimate, adjusting to the Organisation for Economic Co-operation and Development calculation method.
††
Estimated results.
†††
Data for 2007.
85
7. Appropriately
resourced
7. Appropriately
resourced
7.2
Information technology
Information technology (IT) can enhance efficiency and deliver tools that enable high-quality care. The Ontario government created eHealth
Ontario in 2008 to fulfill its promise of “an electronic health record by 2015.” The IT systems of the future should make it possible to easily
share information throughout the healthcare system, as well as supporting clinical decision-making. IT in healthcare refers to secure,
computerized systems designed to collect, manage and relate healthcare information to healthcare providers. An electronic health record
(EHR) is generally defined as a secure and private lifetime record of an individual’s health history and care across the healthcare continuum,
which is available electronically to authorized healthcare providers. In comparison, electronic medical records (EMRs) are less integrated
secure systems, used in one healthcare setting, and are not accessible outside that setting.665 EMRs often also include higher-level
functions that provide decision assist capabilities to providers, such as reminder systems.666
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Electronic entering and storage of notes
and orders.
Illegible handwriting or transcription mistakes may lead to errors, and time
may be wasted searching for missing or misfiled information.
Electronic error checks and reminders of
follow-ups and treatment timing.
Less than optimal drugs may be prescribed, doses may be miscalculated,
drug interactions and allergies may not be flagged and providers may forget
to schedule follow-up tests and visits.
Ontario’s 13 million
residents and healthcare
professionals.
Shared but secure information for providers about
medical history and data such as test results.
Teamwork and communication among providers may not be as effective,
tests may be unnecessarily repeated, the wrong treatments may be recommended if the provider doesn’t have the most current information, and time
may be wasted on repeated data entry.
Access to medical information that helps
individuals better manage their own care.
Delayed communication with a primary care provider or patients with limited
access to their own medical information may lead to patients being less
able to carry out self-management activities, more unnecessary doctor visits
and extra time spent scheduling appointments.
Electronic Medical Record Adoption
ModelSM (EMRAM) score† (from stage 0
to 7), measuring how far acute hospitals have progressed in adopting IT:
Ontario
Small community hospitals
Large community hospitals
Teaching hospitals
Percentage of hospitals that use IT
applications to:
Send electronic referrals
Store electronic patient records
Do computerized practitioner
order entry
Store and retrieve digital images
Time trends & comparisons
Bottom line
Over the last two years, spending on IT has
been gradually increasing among all of the
healthcare sectors except in mental health
and addiction centres. As a whole, however,
the healthcare sector still spends far less than
the banking industry (7%).667, 668 There is room
for improvement.
3.6%*
2.5%
Percent
4
2.0%
0.7%
2
0
2003/04
2009/10
4
BETTER
2.1**
1.7
2.8
3.3
Score
Percentage of budget spent on information systems in:
Hospitals
Community care access centres
(CCACs)
Children’s treatment centres
Mental health and addiction
centres
Value
2
0
Dec-09
Dec-10
100
21%**
60%
13%
89%
BETTER
Percent
Indicator
50
0
Dec-09
Dec-10
Ontario’s hospitals have made progress in adopting IT, but there is room for improvement. Small
community hospitals lag behind the Ontario
average, while large community and teaching
hospitals are above the Ontario average. Only
6% of all hospitals have reached EMRAM stage
4, and North York General Hospital is the first
and only hospital in Ontario to hit stage 5.
More than one in five Ontario hospitals can
send electronic referrals; while one in six have a
computerized entry system for orders. Almost all
hospitals report being able to store and retrieve
digital images; however, only six in 10 hospitals
can store electronic patient records. There is
still room for improvement as the ability to share
electronic information among hospitals is low.
Data sources:
*Ontario Hospital Reporting System, FY 2009/10, provided by MOHLTC.
** HIMSS AnalyticsTM database, December 2010, provided by the Ontario Hospital Association.
†
The Electronic Medical Record Adoption ModelSM score670 is proprietary to HIMSS AnalyticsTM and includes the following categories: 1 — basic IT in pharmacy, lab, X-ray; 2 — data pooled together,
doctors can check results on system; 3 — nursing flow sheets documented electronically, system flags errors; 4 — computerized physician order entry, electronic clinical protocols, can send X-ray
files digitally outside hospital; 5 — advanced tools for drug safety (closed loop medication administration); 6 — doctors enter clinical notes electronically; 7 — paperless hospital.671
86
7.2 Information technology
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Value
Percentage of adults who have
e-mailed their regular doctor’s
practice with a medical question
3.4%***
Time trends & comparisons
10
4,303§
As of September 2010, over 4,300 primary care
physicians have enrolled in provincial EMR adoption programs that support physicians throughout
their effort to use and benefit from EMRs. The
target is to have 9,000 primary care and specialist physicians enrolled by March 2012.669
5000
Number
Only 3.4% of adults in Ontario have e-mailed
their family doctor with a medical question. Both
Ontario and Canada lag behind a number of
countries, and the U.K. has the best results (9.4%).
There is major room for improvement.
UK
GERMANY
US
SWEDEN
NEW ZEALAND
NORWAY
CANADA
ONTARIO
SWITZERLAND
NETHERLANDS
AUSTRALIA
5
FRANCE
Percent
BETTER
0
Number of primary care physicians
that have enrolled in provincial EMR
adoption programs
Bottom line
2500
0
Jan-Mar 06
Oct-Dec 10
Data sources:
***Based on Commonwealth Fund International Survey of Adults, 2010.
§
2006–2010 cumulative data as of November 24, 2010, including data from both the Primary Care Program (implemented in 2005) and the New Adopters program (implemented in November 2009),
supplied by OntarioMD. April to June 2006 data includes cumulative data from July to September 2005, and the score for each quarter is a rolled-up value of the preceding quarter(s).
87
7. Appropriately resourced
7.2
Root Cause
Ideas for Improvement
Concerns about the costs of implementing an
EMR.672 Costs include hardware, software licences,
training, maintenance and upgrades.
Offer incentive programs to either subsidize healthcare providers’ office EMR costs or provide
bonuses for delivering higher quality care.673 In September 2010, Canada Health Infoway pledged
NJMMJPOUPTQFFEVQJNQMFNFOUBUJPOPG&.3TBDSPTT$BOBEB674 Ontario’s EMR Adoption
Program provides funding to promote and support EMR use by community-based physicians.675
Develop a business case for an EMR. For example, at Brigham and Women’s Hospital in
Boston, the implementation of a computerized order entry system resulted in net savings of
NJMMJPOPWFSZFBST676 Consider how an EMR can decrease waste — for example, by
decreasing test repetition, reducing time spent searching for results or entering information, and
reducing the need for clerical personnel.677, 678
Consider the health outcome benefits and cost reductions from better patient care —
for example, reducing health disparities, improving outcomes and providing better continuity of
care.679, 680, 681 Decision support systems can help improve prescribing practices, reduce drug
errors and remind providers when screening is due.682
Concerns about lost productivity when transitioning to an EMR.683, 684 Some physicians report that it
takes months or years to fully implement an EMR.
Healthcare providers may feel there is no incentive to
absorb the cost and hassle.
Lack of comfort with a new system and fear of
problems, such as system crashes, data loss or
security breaches.689
Promote an EMR’s capacity to improve productivity. Once integrated into a practice and its
workflow, an EMR can increase productivity by streamlining processes and reducing duplication,
such as unnecessarily repeated tests.685, 686
Minimize disruptions to workflow and productivity when implementing an EMR by establishing
appropriate procedures and policies early in the process.687 OntarioMD’s Transition Support
Program supports groups through this process.688
Standard protocols exist for when and how to back up data, how to prevent system
errors and data loss, and how to address security and privacy issues.690
Identify champions or leaders.691 Healthcare providers who have experience with EMRs can
reassure others that there are standard protocols to protect against computer problems (e.g.,
back-up systems, firewalls, etc.) or provide tips on how to implement an EMR more smoothly.
Lack of technical expertise and general computer skills,692 such as navigating with a mouse
and typing proficiency.
Consider voice recognition software693 or tablet-based systems to make data entry and
navigation more convenient.
Systems are not very user-friendly and may
have poor interface design — for example,
requiring the user to navigate through too many
menus to access information.
Continue development with input from end users694 to improve functionality and usability of
the systems for users with varied levels of comfort and expertise with IT.
Uncertainty about what type of system to use,
and concerns that it may become outdated.
Promote common standards for data exchange at a provincial or national level, so that even if
a software company fails, key data could still be transferred to another system. Canada Health
Infoway and the Canadian Institute for Health Information established a Standards Collaborative in
2006 to create pan-Canadian standards for EHRs.695
Uncertainty over which software will prevail.
Difficulty using the data in EMRs to monitor quality.
88
Develop standards that specify how EMRs should capture, aggregate and export data
related to quality measures.
7.2 Information technology
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Concerns that true benefits will only be
realized when other parts of the system
are built and an EHR is realized. If other sites,
such as lab or X-ray, cannot send data electronically,
then staff may have to scan information into each
individual EMR, which is inefficient.
Continue investments in disease registries, lab information systems, electronic prescribing
systems and picture archiving and communications systems (PACS) for diagnostic imaging, as
many other countries, and provinces such as Alberta, have done.696, 697 Ensure that providers
have high-speed Internet access so they can send and receive files.
What is Ontario doing?
MOHLTC is focusing on specific EHR-related initiatives, including:
t "
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and costs.
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exchanged among authorized practitioners and lab service providers.
*O4FQUFNCFS$BOBEB)FBMUI*OGPXBZQMFEHFENJMMJPOUPTQFFEVQJNQMFNFOUBUJPOPG&.3T698
89
7. Appropriately resourced
7.3
Healthy work environments
Healthy workplaces make an organizational commitment to safety, emphasizing proper safety training, providing appropriate equipment
(e.g., lifts for moving patients) and carrying out regular inspections to maintain high safety standards. A safe, well-run workplace generally
results in healthier staff, fewer work-related injuries and more satisfied workers — and research shows that satisfied, healthy healthcare
workers are more courteous and less likely to make mistakes due to fatigue or stress.699, 700
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
The lowest possible injury rates for
healthcare workers.
When staff are injured and can’t go to work, those who cover for them have to manage a
greater workload and often experience more stress. This, in turn, may boost staff turnover,
disrupting continuity of care and increasing recruitment-related costs. It may become more
difficult to attract well-qualified workers to the organization. In addition, as Workplace Safety
and Insurance Board (WSIB) claims increase, premiums may rise.
The lowest possible absenteeism
and inactivity rates for healthcare
workers.
High absenteeism rates are disruptive to proper work scheduling and output, and costly to
an organization and the economy as a whole. Absenteeism and inactivity can also be indicative of high worker stress and low job satisfaction.702
Ontario’s 709,000
healthcare and social
services workers,
who represent 9.9%
of the province’s
workforce.701 Their
health matters.
Incidence of
absences (percentage of workers
who report being
absent within the
past week)¶
Inactivity rate
(hours lost as a
proportion of the
usual weekly hours
of all full-time
employees)¶¶
Bottom line
After several years of little change, lost-time and nonlost-time injury rates dropped in 2009, for healthcare
workers in all different settings. From 2008 to 2009, injury
rates decreased by 7% in LTC, 5% in hospitals, 11% for
nursing services, 14% for treatment clinics and 17%
for professional offices and labs. These decreases are
comparable to declines seen in injury rates across all
industries in Ontario.703
10
5
BETTER
2.9
0
2002
2009
1.9
9.1%**
12
6
BETTER
4.9%
The reason for the drop in injuries in all workplaces is not
clear, but lower claims are often observed during recessions.704 This could occur because workers fearing job loss
may avoid claims during recession, or because inexperienced workers are often the first to face work reductions
and these individuals typically have a higher risk of injury.
It will be important to verify whether the reductions in injury
claims seen represent true improvements in safety or simply
a recession effect.
Ontario healthcare workers report being absent from work
12 days per year and 9.1% of them had an absence in the
past week. This rate is higher than the rate for the overall
Ontario workforce (7.8%).705 These rates for healthcare
workers have changed little in the past four years and
there is room to improve.
0
2005
12**
2009
20
Days
Days lost per worker
in year¶¶¶
8.3*
4.7
4.9
Time trends & comparisons
Rate
Lost time and non-lost
time injury rates per
100 full-time equivalent
workers:
LTC homes
Hospitals†
Nursing services
(home care and
other settings)††
Treatment
clinics†††
Professional
offices and labs††††
Value
Rate
Indicator
10
BETTER
0
2005
2009
Data sources:
*
Workplace Safety and Insurance Board, 2009; this indicator represents the total number of injuries causing time away from work (lost time) or not (non-lost time, which includes cases where the
employer provided modified work duties to accommodate a disabled worker) per 100 workers per year.
**
Statistics Canada, special tabulation, unpublished data, Labour Force Survey, 2005 to 2009.
†
Includes acute care, rehabilitation, psychiatric, paediatric and other specialty hospitals.
††
Includes agencies that provide nursing, rehabilitation and personal support services (e.g., homemaking) for provincial home care programs, as well as hospitals or other organizations that need
short-term staff to fill scheduling gaps.††† Includes clinics for mental health and addiction, rehabilitation and public health, as well as community health centres.
††††
Includes offices of doctors, dentists, physiotherapists and other healthcare professionals, medical laboratories, radiology suites, and agencies for research, health promotion, worker safety or
social service planning. ¶Includes absences of any length (e.g. an hour, day or week).
¶¶
This takes into account both the incidence and length of absence.¶¶¶ Calculated by multiplying the inactivity rate by working days per year (250).
90
7.3 Healthy work environments
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Lack of knowledge about safety. Healthcare
workers might not be fully aware of safety hazards
in the workplace or ways to avoid them, including
infection control standards.
Educate staff and supervisors about hazards to their own safety and provide training to reduce their
risk.706 Educate staff and supervisors to look out for safety hazards (e.g., clutter, poor lighting and slippery areas)
and pay closer attention to safe lifting protocols, appropriate use of safety equipment and infection control.
Conduct risk assessments. Have staff use standardized checklists to help them identify environmental
hazards, repetitive motions that could lead to injury and faulty equipment.707
Prevent abuse towards staff.708 Implement standard abuse protocols of zero tolerance. Have security
available, provide panic buttons for staff at high risk, use a buddy system and teach conflict de-escalation
techniques to staff.709, 710, 711
Lack of “safety culture.”712 If safety culture
is weak, then staff may skip safety procedures
when they think they are inconvenient, take too
much time, or are not important. Or, a poor
culture may lead staff to avoid reporting safety
issues due to fear of being punished. Staff then
lose the chance to learn from their mistakes.
Provide visible leadership for workplace safety.713 Set targets with deadlines for reducing workplace
injuries and publicize these widely across the organization. Post frequently updated charts showing progress.
CEOs and managers should “walk the shop floor” to talk about safety and listen to concerns.
Monitor safety statistics, such as injury rates, at the board level. The Duke Health and Safety Surveillance
system was developed to help identify and track health and safety issues, as well as occupational diseases.714
Unhealthy lifestyles can lead to more
illnesses and more absenteeism.
Promote healthy lifestyles within the workplace.715 Encourage activities like stretch breaks in meetings,
healthy food choices for meeting snacks, vending machines and cafeteria food, pedometer or stair climbing
challenges, bike to work campaigns and making bike lockers and/or showers available in the workplace.
Offer tobacco cessation programs and universal flu vaccination.
Excessive workloads may lead to fatigue,
stress or burnout,716 which can also increase
the risk of workplace accidents and absenteeism.
Allow frequent breaks to ease fatigue, and give staff the opportunity to eat and drink to maintain
energy.717
Consider how staff can be used more effectively to decrease time pressures on them. This could
involve improving teamwork and work processes, eliminating unnecessary or redundant tasks, and
improving role clarity.
Consider increasing staffing levels, but only after all efforts to increase efficiency are exhausted.
Lack of safety equipment. Staff do not always
have access to equipment that could reduce
their risk of injury from performing their duties.
Environmental hazards innate to healthcare
settings (e.g., sharps, infectious diseases) can
also cause injury or harm.
Ensure that adequate safety equipment is available to healthcare providers and staff and that they are
trained in this equipment’s proper use. For example, musculoskeletal injuries from heavy lifting (e.g., while
moving a patient out of bed) are very common in healthcare.718 Use mechanical lifts to assist with patient
transfers. Needleless IV systems can help reduce needle stick injuries.719 Consider ergonomic workstations
to reduce injuries related to repetitive strain.720, 721 Make sure all providers and staff have appropriate
infection control training and materials (e.g., conveniently located sinks, gloves and masks).
High prevalence of shift work. Healthcare is a
sector where employees frequently work shifts.
There is a persistently higher risk of work-related
injury for extended duration work shifts,
particularly during the night.722
Implement strategies to mitigate the effects of shift work.723 Provide employees with information
about sleep hygiene, and encourage strategies that can be used to reduce fatigue, such as napping.724
Consider altering shifts to make them more compatible with circadian rhythms and provide adequate
recovery time between shifts, especially when rotating off night shifts.725
What is Ontario doing?
t #
JMMXIJDIBNFOEFEUIFOccupational Health and Safety Act (OHSA) to prevent violence and harassment in the workplace, came into effect on
June 15, 2010.726 The final phase of the Needle Safety Regulation, which requires all healthcare workplaces to use safety-engineered needles, came
into effect on July 1, 2010.727 And the Excellent Care for All Act, which requires healthcare organizations, starting with hospitals, to develop worker
satisfaction surveys, passed on June 3, 2010.728
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tools and resources to promote healthy work environments.
t )
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leadership in creating healthy and productive workplaces in Ontario.729 HealthForceOntario also launched a social media initiative in the summer of
2010, including a Twitter feed (@HFO_HWE), to promote healthy work environments.730
91
7. Appropriately resourced
7.4
Health human resources
It’s clear that having enough staff is essential to deliver high-quality healthcare, but researchers and planners struggle to define the optimal
number, mix and distribution. Variables include the demand for healthcare, model of care selected, worker productivity and number of
hours staff are willing to work. As new models are developed and work is structured more efficiently, human resources targets can change.
MOHLTC has not yet set any official planning targets in this area, so this report will not comment on whether greater supplies of professionals are positive or negative. It will, however, indicate whether Ontario appears to be moving towards more team-based care in primary care
practices — an important factor when it comes to delivering excellent, efficient care.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
The right number and type of healthcare practitioners available when Ontarians need them.
Too few healthcare practitioners may lead to increased wait times, more
travel to get care and, in some cases, no access to certain services. Providers compensating for the shortfall may experience extra workload and stress.
Ontario’s 13 million
residents.
Number of entry-level student
positions for:
Registered practical nurses
Registered nurses
Nurse practitioners
Value
Time trends & comparisons
3,226*
4,345*
176*
0
Percentage of physicians within
the workforce who can provide
professional services in French
2009/10
876*
1,000
Number
221
500
849**
0
2005/06
2009/10
387*
90*
750
88**
11***
712***
231***
Rate
Supply per 100,000 people of:
Family doctors
Nurse practitioners
Registered nurses
Registered practical
nurses
Specialists
Over the past four years, the number of entry-level
student positions in healthcare has steadily increased
in Ontario. The greatest increases have been seen in
the number of positions for nurse practitioners (76%),
pharmacists (61%), midwives (41%) and registered
practical nurses (52%). Further, the number of
positions for international medical graduates has
increased by 42% over the past four years.
2,500
2005/06
Undergraduate medical
students
International medical
graduates entering postgraduate training and
assessment†
Canadian medical graduates entering MOHLTCfunded residency training
Pharmacists
Midwives
Bottom line
5,000
Number
Indicator
375
0
99**
2000
2009
16%§
Percent
20
10
0
2004
2009
From 2005 to 2009, there has been an increase in the
supply of family doctors (3.4%), specialists (6.4%) and
nurse practitioners (83%) per 100,000 people. However, at present, there is only one nurse practitioner
for every eight family physicians in Ontario. Also, large
regional variations are present across the province in
the supply of healthcare providers (see LHIN analyses,
chapter 11).
Close to 5% of Ontarians speak French.731 Almost one
in six Ontario doctors can provide services in French.
In addition, 8.8% of many health professionals, such
as dentists and optometrists, are also able to provide
services in French.§ Thus, the proportion of healthcare
providers who speak French is greater than the proportion of the Ontario population that is francophone.
While this is encouraging, it will be important to verify
that these French-speaking physicians are located
where francophones live.
In addition, almost one in five health professionals
report being able to provide services in a language
other than French or English.§
Data sources:
*
Entry-level student positions data provided by MOHLTC and MTCU for academic year 2009/10.
**
Ontario Physician Human Resources Data Centre, 2009.
***
College of Nurses of Ontario, 2010.
§
College of Physicians and Surgeons of Ontario, Ontario Physician Human Resources Data Centre, 2009, calculated by HQO.
†
These data reflect only students funded by MOHLTC; MOHLTC has set a target of 200 registered international medical graduates per year, and continues to surpass this target.
92
7.4 Health human resources
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
What is Ontario doing?
t .
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province and 9,600 nurses have participated to date.734
t .
0)-5$IBTOBNFETJY'SFODIMBOHVBHFIFBMUIQMBOOJOHFOUJUJFTUPXPSLXJUI-)*/TUPFOTVSFMPDBMIFBMUIQMBOOJOHSFnFDUT'SBODPQIPOFDPNNVOJties’ needs.735
t 0
OUBSJPTmSTUDMBTTPG1IZTJDJBO"TTJTUBOUT1"T
HSBEVBUFEPO/PWFNCFSGSPN.D.BTUFS6OJWFSTJUZ736 and University of Toronto now
also offers the two year Physician Assistant training program. Working under a medical doctor’s supervision, physician assistants are now being
deployed in family health teams, community health centres, emergency departments and hospitals.737, 738
93
8. Integrated
8.1
Discharge/transitions from hospital and primary care
When Ontarians move from one provider or setting to another — for example, from a hospital back to the community — there is a risk that
poor communication may lead to errors739 that adversely affect patient care and health outcomes. To mitigate this risk, healthcare
providers must share all key information in a timely fashion, and any necessary follow-up care must be arranged.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
All relevant information provided to patients
when they are discharged from a hospital or
emergency department (ED) to their homes,
including warning signs to watch for, side
effects of new drugs and where to go if they
have problems.
When patients don’t receive or understand the information they need at
discharge, they may not get proper follow-up or know what they need to do
to take care of themselves. This increases the chance their health may get
worse and they may have to return to hospital.740
Ontario’s 20% of
residents who visit an ED
each year,741 and the Ontarians who account for
over one million hospital
discharges each year.742
Follow-up by a physician within 30 days for
patients discharged from hospital for mental
health services.
After discharge, people with mental health conditions may return to stressful
situations at home, or have side effects of their medication, or may stop
their medications prematurely. Early follow-up helps identify these problems
and address them before they escalate. Without follow-up, these individuals
are more likely to end up back at hospital.743
The approximately
42,000 people in Ontario
who were discharged
from hospital for a
mental health and addictions condition in FY
2009/10.744
Rehabilitation services for most patients after
hospitalization for a stroke.745
When people recovering from a stroke don’t receive rehabilitation services,
they may have to live with worse speech or movement disabilities.746
Ontario’s 90,000 people
living with the effects of
strokes.747
Indicator
Percentage of patients who knew:
Danger signals to watch for after going home
Hospital
ED
Value
51%
80%
How to take medications
ED
83%
Side effects of medications to watch for
Hospital
64%
70%
When to resume usual activities
Hospital
52%
Whom to call if they needed help
Hospital
80%
ED
BETTER
61%
0
Data sources:
*NRC-Picker patient satisfaction surveys, FY 2009/10, provided by the Ontario Hospital Association.
94
Bottom line
A large proportion of patients
are not receiving the information they need upon leaving the
hospital or ED. For example,
only half of hospital patients
know when to resume normal
activities. Only half of ED
patients know what danger
signs to look out for at home.
About one in three patients do
not know what side effects of
medications to look out for.
These rates have not changed
over the past three years (data
available on request). There is
huge room for improvement.
59%*
Purpose of medications
Hospital
ED
Time trends & comparisons
50%
100%
8.1 Discharge/transitions from hospital and primary care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Value
Percentage of adults who report their
regular doctor/general practitioner practice seems informed about the care they
received in hospital, including any new
prescription medications
68%**
Time trends & comparisons
100
US
SWITZERLAND
NEW ZEALAND
UK
AUSTRALIA
ONTARIO
SWEDEN
NETHERLANDS
CANADA
GERMANY
61%**
100
NEW ZEALAND
SWITZERLAND
US
AUSTRALIA
ONTARIO
UK
GERMANY
CANADA
FRANCE
NETHERLANDS
100
Rate
61***
71
70
NORWAY
50
SWEDEN
Percent
BETTER
0
30-day post-discharge rate of
physician visits per 100 people for:
Any mental health or addiction
Depression
Schizophrenia or bipolar disorder
FRANCE
50
NORWAY
Percent
BETTER
0
Percentage of adults who report their
regular doctor/general practitioner practice seems informed and up to date about
the care they received in an ED
Bottom line
BETTER
50
0
2002/03
Percentage of stroke patients
discharged from acute care to
in-patient rehabilitation
2009/10
29%§
40
Percent
BETTER
20
0
2005/06
2009/10
Only 68% of adults in Ontario
who had been in hospital felt that
their regular doctor seemed
informed about the care they
received while in hospital.
Internationally, Ontario is in
the middle of the pack in this
area, and the US has the best
results, at 92%. There is major
room for improvement.
Only 61% of adults in Ontario who
had visited an ED felt that their
regular doctor seemed informed
and up-to-date about the care
they received while in the ED.
Ontario and Canada have results
that are similar to several other
countries. This is a problem that
persists around the world. There
is major room for improvement.
Nearly four out of 10 patients
are not receiving recommended
follow-up with their primary
healthcare physician within
30 days of discharge for a mental
health or addictions condition. No
major change has been seen in
the past three years and improvement is necessary.
Across Ontario, 29% of acute
care stroke patients receive
in-patient rehabilitation following
their stroke. This is likely too
low, as the percent of stroke
patients who have a level of
disability that typically requires
in-patient rehabilitation is approximately 40%.748 There has
been no change in the past four
years, and there is likely room
for improvement.
Data sources:
**Based on Commonwealth Fund International Survey of Adults, 2010.
***Discharge Abstract Database (DAD), Ontario Mental Health Reporting System, Ontario Health Insurance Plan (OHIP), Registered Persons Database (RPD), FY 2009/10, calculated by Institute for
Clinical Evaluative Sciences (ICES). Indicator methodology adapted from the POWER Report.749
§
DAD, National Rehab System Database, FY 2009/10, calculated by ICES; includes only patients treated in stroke centres in Ontario.
95
8. Integrated
8.1
Root Cause
Ideas for Improvement
Issue: Patients do not receive or understand discharge instructions.
Healthcare providers may forget to
provide all relevant details about
discharge care to patients.
Provide written discharge instructions for all hospital and emergency department patients.750, 751
Duplicates should be made, with one copy given to the patient and the other kept in the chart. Use a standard
sheet for certain common conditions (e.g., gastroenteritis, head injury), with room to add details unique to the
patient. Structure the form to ensure that the key details (e.g., how to take medications, symptoms or side
effects of drugs to look out for, or whom to call if things get worse) are always included.
Patients may be too stressed with
their medical condition and forget
discharge instructions when given.
Use the “teach back” method.752, 753 Ask patients to repeat discharge instructions to verify that they
understand them. If they don’t, clarify errors and try again. Consider requiring staff to record in the chart
whether the “teach back” confirmed understanding of written discharge instructions.
Staff explain instructions at a level
of language that patients cannot
understand, or patients don’t
understand English well.754
Have interpreter services available, with interpreters who are trained in medical terminology755 for
commonly spoken languages in the community. Also have information available in multiple languages that is
written in plain language.
Patients may receive different
instructions from different providers.
Consider having the most responsible physician in the hospital call the patient’s family physician to
discuss a discharge plan, especially for complex internal medicine or mental health patients.
Patients and family members may feel
uncomfortable asking questions to
clarify instructions (see section 5.1).
Give patients and families a chance to ask questions.757 Clarify misunderstandings and ask if there are
any questions or if there are instructions that they will have difficulty following.
96
Provide patients and families with simplified instructions, using plain language; written material could
also use pictures to reinforce instructions.756
8.1 Discharge/transitions from hospital and primary care
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Issue: Discharge information is not received by primary care provider, or is incomplete.
Some doctors don’t dictate discharge
summaries immediately after
discharge. This slows the transfer of
information to primary care providers,
and may also contribute to information
about hospital visit being incomplete.
Try database-generated discharge summaries, where much of the key information is captured using a
standard form instead of traditional voice dictation. Studies show that in some instances, electronic discharge
summaries are faster than dictating summaries, capture more useful information, and healthcare providers
receiving the reports find them easier to read.758, 759
Delays in getting information to the
healthcare provider.
Use fax or secure e-mail instead of regular mail to send out reports.760 Ideally, transmit this information electronically from hospitals to electronic medical records in primary care offices. Use of a web-based
standardized communication system to transfer information on patients’ visits to emergency departments to
family doctors makes transfer of information more timely and complete.761
Track discharge dictation delays and feed data back to family doctors or healthcare providers.
Set standards in hospital for discharge summary dictation delays. For physicians who habitually delay
discharge summaries, revoke hospital privileges as a last resort.
Set standards and measure timeliness of information transfer between in-hospital provider and
primary care provider. One source recommends that diagnoses, medications, results of procedures,
pending tests, follow-up arrangements and suggested next steps be communicated to primary care providers
on the day of patient discharge, and detailed discharge summary be received by primary care physician within
one week of discharge.762
Issue: Transfer to rehabilitation following stroke.
Not enough spaces in rehabilitation
facilities and outpatient rehabilitation options to accommodate
stroke patients.
Ensure the right capacity exists for stroke rehabilitation care. This consists of specialized stroke
rehabilitation units as well as outpatient rehabilitation programs.763
What is Ontario doing?
The Ontario Association of Community Care Access Centres (OACCAC) is in the process of implementing a survey to home care clients that will help
track how well care is integrated from discharge to return back to home.
97
9. Focused on population health
9.1
Unhealthy behaviour
The basis of good health is healthier behaviour.767 That includes avoiding smoking and heavy drinking, maintaining good physical activity,
preventing obesity and enjoying a healthy diet that includes a variety of fruits and vegetables. Adopting a healthy lifestyle is essential to
avoiding chronic diseases later in life.768 Improvements in health also require supportive environments, policies and resources that enable
people to achieve their full health potential.769
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
No smoking or exposure to
second-hand smoke.
Smoking raises the risk of cancer, lung disease, heart attack, stroke, emphysema, pregnancy
complications and other conditions.770 It kills more than 13,000 people in Ontario each year771
and is the number one cause of premature mortality. Smoking also accounts for at least
500,000 hospital days per year.772"OOVBMDPTUTPGTNPLJOHJODMVEFCJMMJPOPOIFBMUIDBSF
BOECJMMJPOJOMPTUQSPEVDUJWJUZ773.
Ontario’s 13 million
residents.
No heavy alcohol consumption.
Heavy alcohol use raises the risk of cirrhosis of the liver, pancreatitis and chronic gastritis
(irritation and bleeding of the stomach),774 as well as mouth, throat, esophogeal, colorectal and
breast cancer.775 It is also associated with a higher risk of injuries and violent behaviour.776
Everyone at a healthy weight.
Obesity raises the risk of heart disease, stroke, diabetes, several kinds of cancer (including
breast, colorectal, esophogeal, pancreatic, endometrial and kidney),777 arthritis of the knee and
many other conditions.7780OUBSJPTQFOETOFBSMZCJMMJPOFBDIZFBSPOPCFTJUZNJMMJPO
JOEJSFDUBOENJMMJPOJOJOEJSFDUDPTUT779, 780
Everyone more physically
active.
Physical inactivity raises the risk of cancer,781 obesity, heart disease, diabetes, osteoporosis and sleep
disturbances.7820OUBSJPTQFOETCJMMJPOFBDIZFBSPODPTUTSFMBUFEUPQIZTJDBMJOBDUJWJUZ783, 784
Everyone eating enough fruits
and vegetables.
Eating fewer than five servings of fruits and vegetables every day raises the risk of heart
disease, stroke, obesity,785 and stomach, esophogeal, lung and colorectal cancer.786
Percentage of the
population:
Who smoke
Who are
exposed to
second-hand
smoke
Value*
Time trends & comparisons
Bottom line
100
19%
18%
Percent
Indicator
50
BETTER
0
2001
2009
Percent
100
50
BETTER
0
2001
22%
2009
100
Percent
Percentage of the
population who have
had binge drinking
episodes†
Smoking rates in Ontario have decreased sharply over the
past eight years, from 25% to 19%. This represents a 25%
relative decrease. The rate of second hand smoking has
decreased even more sharply, from 27% in 2003 to 18% in
2009. Anti-smoking laws passed at the provincial, municipal
and federal level over the past 15 years have likely contributed to these declines. These laws include restrictions
on advertising787, sponsorship of events, sales to minors788,
smoking in the workplace, and graphic warning labels.789 The
2006 Smoke Free Ontario Act extended smoking bans to all
enclosed public places, including restaurants and bars.790
50
BETTER
0
2001
2009
Although smoking has declined, there is still room to improve.
Ontario could aim to match BC’s smoking rate (16%)791 or
Toronto’s (13%). Toronto’s success may possibly be due to its
longer experience with anti-smoking bylaws (for example, it
banned smoking in restaurants in 1999).792 Those with low
education, low income or who live in rural areas are much
more likely to smoke (for example, 30% among those who do
not complete high school). Efforts targeted to these groups
could reduce smoking further (see section 10.2).
More than one in five Ontarians report having had binge drinking episodes. There was a slight increase in this rate of from
2001 to 2003 but since then there has been no change. Ontario does have the lowest rate of heavy drinking in Canada,793
but there is still room to improve. Men and rural residents are
at greater risk, and efforts could be targeted to these groups
(see section 10.2).
Data source:
*
Canadian Community Health Survey, population represents respondents ages 12 and over, 2009, calculated by Institute for Clinical Evaluative Sciences.
†
Defined as having five or more drinks on one occasion, at least once within the year.
98
9.1 Unhealthy behaviour
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Value*
Percentage of the
population who are
obese††
18%
Time trends & comparisons
Bottom line
Percent
100
50
BETTER
0
2001
49%
100
Percent
Percentage of the
population who are
physically inactive
2009
50
BETTER
0
2001
56%
100
Percent
Percentage of the
population with
inadequate fruit and
vegetable intake
2009
50
BETTER
In 2009, 18% of Ontarians reported being obese. Because information is self-reported, the true rate is likely higher. Obesity
has gotten slightly worse over the past eight years, and there
is huge room to improve. Ontario could aspire to match obesity
rates of 10% to 11% in Sweden, Norway, Italy, the Netherlands
and France.794 Obesity is higher among those without high
school education (23%) and living in rural areas (22%; see section 10.2). While efforts targeted to these groups could help,
the problem is so widespread that approaches directed to the
entire population are also needed.
Half of Ontarians do not get enough physical activity. Because
this information is self-reported, the true rate of physical
inactivity is likely even higher. There has been no significant
change over the past eight years and there is major room for
improvement. Ontario is similar to the national average (48%),
but much worse than B.C. (40%), and short of the target of
45% it declared in 2005.795 Rates of physical inactivity are
worse among those with lower education (70%) and low income (61%; see section 10.2). Efforts targeted towards these
groups, as well as to the entire population are needed.
56% of Ontarians do not consume enough servings of fruits
or vegetables every day (i.e. five or more). There has been
no major improvement in this indicator since 2003. Ontario’s
results are similar to the national average but worse than
Quebec’s (46%).796 There is room for improvement.
0
2001
2009
Data source:
*Canadian Community Health Survey, population represents respondents ages 12 and over, 2009, calculated by Institute for Clinical Evaluative Sciences.
††
Defined as body mass index of 30 or more.
99
9. Focused on population health
9.1
Root Cause
Ideas for Improvement
Harmful substances, particularly tobacco,
are highly addictive.
Encourage the use of nicotine replacement therapies (NRTs) such as nicotine gum, sprays, patches
or lozenges.797 Consider increasing their access to all people regardless of drug coverage plans.
Poor health habits may be a social norm.
“De-normalize” unhealthy behaviours.798 Smoking bans in public places are effective in reducing
smoking.799, 800 Similarly, consider limiting unhealthy food choices in school and workplace cafeterias801 and remove junk food vending machines from schools.802
Encourage healthy work environments. Employers can offer physical activity programs, workshops, classes and other resources at the workplace.803 Employers can also serve fruits and vegetables at meetings instead of pastries and desserts.
Motivation issues and/or low self-esteem
may exist. People may not be motivated to
change, or may not feel as if they have the power
to do so.
Promote patient self-management,804, 805, 806 preferably through a counsellor with certified training
in these techniques.807, 808, 809 Patients learn about their condition and are coached into setting their
own reasonable goals for improvement (e.g., “I’ll start by losing two pounds in the next three weeks”)
that fit with their lifestyle (e.g.,“I’ll have green tea instead of a double-double at my bridge game”).
Then, they build gradually on each improvement.
Poverty and/or low education contribute to
unhealthy behaviours. Individuals struggling with
daily survival may not have the time or energy to
maintain a healthy lifestyle.
Develop targeted outreach activities to low socioeconomic groups that help address their
underlying challenges in maintaining healthy lifestyles. See section 10.2 for details.
Knowledge and awareness gaps exist. While
most people know unhealthy behaviours should
be avoided, they may not be aware of how
different choices can affect their health, or the
specific steps they need to follow.
Providers can refer people to smoking cessation programs, smoking hotlines or healthy eating
hotlines for more information (see page 101).
Give “exercise prescriptions”,810 which tell patients precisely what frequency, intensity, type and
duration of exercise they should follow, given information about their current fitness level.
Dispel the myth that healthy eating is expensive. Promote low-cost healthy foods such as eggs,
milk, potatoes, whole grain breads and pasta, oats, beans, apples, bananas, broccoli, spinach,
watermelon and squash.811
Display calorie and sodium content on menus in restaurants and school and workplace
cafeterias, to help consumers make informed choices.812
Simplify routines. Create written instructions in plain language or simple checklists (e.g., a shopping
list of healthy foods, walking program) for patients to follow.
100
Unhealthy food choices are
aggressively marketed.
Create health promotion materials including posters, pamphlets, videos and other educational
materials that use simple wording and are available in multiple languages to meet patient needs.813, 814
Post materials in healthcare settings, community centres, libraries and other public places where
vulnerable populations meet.
Healthy choices may not be accessible.
Enable healthy environments and active lifestyles through community planning and development.
Ensure neighbourhoods are safe and pedestrian-friendly, and that people from all income levels have
access to recreational facilities.815, 816 Keep physical activity and recreation an integral part of the
school curriculum817 (see section 10.2).
9.1 Unhealthy behaviour
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Healthcare providers are challenged to find
time to discuss health behaviours.818
Use decision aids, flow sheets and computerized reminder systems819, 820 to track health
promotion activities.
Involve all members of the healthcare team (e.g. have nurses and health promotion educators
offer lifestyle counselling.821
Try the “Ask, Advise, Assist, Arrange” protocol that nurses or other practitioners can use at every
health encounter to counsel on smoking. This takes only three minutes to do.822
Ensure provider reimbursement systems encourage behavioural risk counselling and other
prevention activities.
What is Ontario doing?
t &
BU3JHIU0OUBSJPXXXPOUBSJPDB&BU3JHIU
JTBGSFFUFMFQIPOFBOEFNBJMTFSWJDFPGGFSJOHJOGPSNBUJPOBCPVUGPPEBOEOVUSJUJPO
meal planning advice, healthy eating tips and recipes.823 The Canadian Cancer Society’s www.smokershelpline.ca (1-877-513-5333) provides a
similar service for smoking.824
t 1
SPNPUJOH-JGFTLJMMTGPS"CPSJHJOBM:PVUI1-":
JTBQJMPUQSPHSBNEFWFMPQFECZ3JHIU5P1MBZJOQBSUOFSTIJQXJUIUIFQSPWJODFBOEPUIFSPSHBOJ[Btions, to help Aboriginal youth improve their health, self-esteem and leadership skills through participation in sport and play activities.825
t *O0OUBSJPMBVODIFEBOBGUFSTDIPPMQSPHSBNUPQSPWJEFDIJMESFOJOBUSJTLDPNNVOJUJFTXJUIOVUSJUJPOBOEQIZTJDBMBDUJWJUZQSPHSBNT826
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FHJOOJOHJOTQSJOHQBSUJDJQBUJOHGBNJMZIFBMUIUFBNT')5T
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patients who want to quit smoking.827
101
9. Focused on population health
9.2
Maternal and infant health
In the development of a child, the time from conception to three years after birth is critical.828, 829 During this time, both the mother’s and
infant’s health must be carefully monitored, since problems that are left undetected or untreated may have consequences that last for years
or for a lifetime.830
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
All steps are taken to avoid preventable
infant deaths (e.g. avoid sudden infant
death syndrome, injuries).
More infant deaths.
Babies born with a healthy weight.
Low birth weight raises the risk of death at birth832 and at all stages of life.833 It may
also result in learning difficulties,834 high blood pressure, heart disease,835 diabetes,836, 837 asthma and hearing and vision problems838 later in life.
Ontario’s approximately
138,000 women who
gave birth last year and
their families.831
No smoking by pregnant women.
When pregnant women smoke cigarettes there is an increased risk of pregnancy
complications and serious adverse fetal outcomes, including low birth weight,
stillbirth, spontaneous abortion, decreased fetal growth, premature birth, placental
abruption, and sudden infant death syndrome (SIDS).839, 840
At least six months of breastfeeding
after birth.
When mothers do not breastfeed for at least six months after their baby’s birth, it
may result in less bonding between mother and infant,841 more infections and allergies842 and possibly a greater risk of diabetes later in life.843 In addition, breastfeeding mothers experience less ovarian cancer, breast cancer and osteoporosis.844
Value
Infant mortality rate†
(per 1,000 infants)
5.2*
Time trends & comparisons
Bottom line
10
Percent
Indicator
5
BETTER
Infant mortality has been steady in Ontario over the
last several years at 5.2 deaths per 1,000. This rate
is higher than the rate of 4.0 in B.C.845 and 2.5 to 2.7
in Japan, Norway, Sweden and Finland.846 There is
room to improve.
0
2000
6.2%**
10
Percent
Percentage of babies with
low birth weight
2007
5
BETTER
0
2000
12%***
100
Percent
Percentage of women
who smoked during
their pregnancy
2007
50
BETTER
In Ontario, close to one in 17 babies are born with
a low birth weight, weighing less than 5.5 pounds.
In 2007, Ontario tied with Nunavut for the thirdhighest rate of low birth weight babies in Canada,
behind Alberta (6.5%) and Yukon (6.4%). This rate
has increased by one-tenth over the past seven
years. This may be due to an increase in maternal
age, the use of assisted reproductive technology,
and multiple births.847, 848
About one in eight women smoke during their pregnancy. No change has been seen in the past three
years. There is substantial variation within the province (with Central LHIN having the lowest rate at 4%).
This suggests that there is room for improvement.
0
2000
100
88%§
23%
Percent
Percentage of mothers
breastfeeding:
Initiation
Exclusively for
six months
2007
50
BETTER
0
2005
9.2.6 Maternal and Infant Health
2009
Almost nine in 10 new mothers initiate breastfeeding
after birth. However, many women stop breastfeeding too soon. Only one in four continue to breastfeed
their babies exclusively for six months after birth, as
recommended by the World Health Organization.849
Breastfeeding rates have decreased in the past year,
and Ontario lags behind the national average and BC’s
rate (34%).850 There is room to improve.
Data sources:
*
Statistics Canada, 2008, CANSIM table 102-0504. Infant mortality rate is the number of deaths of children less than one year of age, per 1,000 live births.
Statistics Canada, CANSIM table 102-4005. Low birth weight (less than 2,500 grams) and borderline viable birth weight-adjusted low birth weight (500 to less than 2,500 grams), by sex, Canada,
provinces and territories, annual.
***
Niday Perinatal Database, provided by BORN Ontario, FY 2009/10.
§
Statistics Canada, 2009, CANSIM table 105-0501. † includes infant deaths occurring at one year of age or younger.
**
102
9.2 Maternal and infant health
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Issue: Infant mortality.851
Parents are unaware of, or do not take steps
to avoid sudden infant death syndrome
(SIDS) or preventable injuries.
Provide public education for parents on use of restraints in equipment such as strollers and high
chairs; proper use of car seats; and how to baby-proof the home. For SIDS, tips include sleeping on
the infant’s back, eliminating second-hand smoke and clutter in cribs and avoiding overdressing.852 Public education can be provided by public health units, primary care and prenatal classes.
Clinical aids such as the Rourke Baby Record853 remind healthcare providers to ask about and record
key information at each visit, including safety issues.
Low birth weight.
See below.
Complications at pregnancy.
Ensure good pre-natal care to reduce complications such as Group B Strep infections or sexually
transmitted diseases passed on to infant. Identify and address problems with addictions, poor nutrition
or risky health behaviours.
Congenital anomalies.
Screen for congenital anomalies in pregnancy. If the pregnancy is continued, the information may
help anticipate problems at delivery.
Health inequities. Infant mortality is higher in
aboriginal communities854, 855, 856 and mothers with
low education857 or income.858, 859
Consider targeted outreach programs, with education materials on safety tailored to these groups.
Providers can seek out individuals at risk to encourage them to attend pre-natal care visits, or call
them if they have missed appointments.
Issue: Low birth weight.
More pre-term babies being born, due to
increased use of fertility treatments, particularly
by older women, that lead to multiple births.860
Consider educating the public about the risks of delayed childbirth to help women and families
make informed decisions. Finding ways to support women to have their children earlier without
adversely affecting their careers could reduce the need for fertility treatment.
Poor maternal health, or poorly controlled
chronic diseases like diabetes.
Ensure universal access to primary care services (see section 2.2). Offer prenatal care programs
targeting the specific needs of their populations, as many Community Health Centres have done.861, 862
Smoking and drug addictions.
Ask about addictions and offer counselling.
Poor diet, which is more common in women with
low income or education level (see Section 10.2).
Provide nutrition outreach programs that offer dietary education and supplements to disadvantaged
pregnant women. The Canada Prenatal Nutrition Program (CPNP) funds such programs.863
Issue: Low rates of breastfeeding.
People are unaware of recommendations for
exclusive breastfeeding to six months (instead of
four, as previously recommended).864
Ensure educational materials have been updated to reflect the new recommendation of six
months. Consider embedding reminders in electronic medical records to healthcare providers
to continue advocating breastfeeding to six months.
New mothers may struggle or become
discouraged with breastfeeding.865
Provide access to lactation consultants, clinics or home visits to help mothers with proper
latching technique and suggest remedies for complications like sore nipples or mastitis.866, 867
Spread the word about breastfeeding support groups (e.g., La Leche League).868
Lack of public acceptance of breastfeeding
in public places and the workplace.
Encourage public places (e.g. shopping malls) to provide private spaces for breastfeeding, and
employers to offer breaks and quiet places for women to pump breast milk.869
What is Ontario doing?
t .JEXJWFTBUUFOEFENPSFUIBOPGCJSUITJO0OUBSJPJO':BTTJTUJOHBCPVUXPNFO870
t *OQBSUOFSTIJQXJUIUIF#SFBTUGFFEJOH$PNNJUUFFGPS$BOBEBUIF0OUBSJP#SFBTUGFFEJOH$PNNJUUFFJTJNQMFNFOUJOHUIF8PSME)FBMUI0SHBOJ[BUJPO
UNICEF Baby-friendly Hospital Initiative (BFHI), helping hospitals and community health services achieve the baby-friendly designation.871 The BFHI
includes a course for maternity staff and tools for self-appraisal, monitoring and reassessment.872
103
9. Focused on population health
9.3
Sexual health
Sexual health, according to the World Health Organization, is “a state of physical, emotional, mental and social well-being related to
sexuality.”873 It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having
pleasurable and safe sexual experiences, free of coercion, discrimination and violence.874 This section focuses on three sample
indicators of sexual health. In future reports, HQO plans to provide a broader perspective on this important topic.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
A reduction in the incidence of
sexually transmitted infections,
including gonorrhea, syphilis
and HIV.
Left untreated, gonorrhea can lead to pelvic inflammatory disease (PID) in
women, which can lead to chronic pelvic pain and scarring of the fallopian
tubes, infertility and increased risk of ectopic pregnancies.875 Infections can
lead to male infertility.876
All Ontarians benefit (including
those who are sexually active) from
the reduction in incidence as the
burden of these infections on the
healthcare system is reduced.
Syphilis starts as an open sore and may be followed by rashes, fever, and
muscle and joint pain. Later on, syphilis can damage the brain, blood vessels,
heart and bones, and eventually lead to death.877
HIV is a chronic infection impairing the immune system and can lead to infections,878 cancers,879 dementia,880 other major physical impairments, and AIDS.881
A reduction in teen pregnancies.
Value
Gonorrhea rate per
100,000 people
27*
Time trends & comparisons
Ontario’s 409,000 females aged
15 to 19.886
Bottom line
40
Rate
Indicator
For teens, pregnancy is associated with an increased risk of anemia, high blood
pressure, eclampsia and depression.882 Teen mothers are more likely to drop out
of school, be on social assistance and live in poverty.883 In addition, teen pregnancies have an increased risk of low birth weight and pre-term birth. For babies,
this can lead to a higher risk of death, developmental problems, learning difficulties, hearing and visual impairments and chronic respiratory problems.884 When
they grow up, the children of teen mothers are also at greater risk of becoming
teen parents themselves, perpetuating the cycle of teen pregnancy.885
20
BETTER
In 2009 there were approximately 3,500 confirmed cases
of gonorrhea. The majority of these cases were among those
aged 15 to 34, although the peak age for men starts later
than women. No major change has been seen in the past five
years. Improvement is necessary.
0
2004
6.0*
40
Rate
Infectious syphilis rate
per 100,000 people
2009
20
BETTER
There were nearly 800 confirmed cases of infectious
syphilis in 2009. More than 95% of the cases were men,
and of those more than half were aged 25 to 44. This rate
has increased over the past five years and improvement
is necessary.
0
2004
7.8**
10
Rate
HIV incidence per
100,000 people
2009
5
BETTER
0
2004
2009
Slightly more than 1,000 Ontarians were diagnosed with HIV
last year. There has been an 18% decrease in HIV incidence
over the last five years in Ontario. According to the UN,
declines in HIV incidence have also occurred around the
world.887 The reasons for this are not clear; one possibility is
that at-risk populations are taking greater precautions (e.g.,
safe sex). Although these improvements are welcome, there
are still huge opportunities to reduce HIV incidence further.
Data sources:
*Public Health Division, MOHLTC, 2009. **Public Health Laboratory Toronto, Ontario Agency for Health Protection and Promotion, 2009.888
104
9.3 Sexual health
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Lack of knowledge about sexual health.
People may lack information, skills and attitudes
necessary to make decisions that promote and
maintain their sexual health and prevent unintended
pregnancies and sexually transmitted infections.
Provide access to comprehensive, relevant and accurate sex education in an age-appropriate,
culturally sensitive manner that is respectful of individual sexual diversity, abilities and choices.890 This
education has historically occurred in schools and community settings with positive results.891 Also
consider public awareness campaigns (e.g., radio, television, billboards) and online information, which
potentially offers greater anonymity and more current, interactive information than pamphlets (see the
Society of Obstetricians and Gynaecologists of Canada’s ”Sexuality and U” site).892
People, particularly young people, may feel
invulnerable and may underestimate the
risk889 of sexually transmitted infections and
unwanted pregnancy — the “It’ll never happen
to me” attitude.
Prepare parents to talk openly with their children about sexual health.893 Specific tips include
talking to their children about sex early and often, always knowing where their teen is, knowing their teen’s
friends and families, encourage group activities over frequent dating, strongly discouraging their teen
from dating someone who is more than two years older, knowing what their teen reads, watches or listens
to, and be aware of inappropriate sexual messages in popular media.894
Lack of communication between partners.
People may feel uncomfortable, embarrassed
or fearful of talking openly about sex with
their partners.
Strengthen skills in decision-making and assertive communication. This involves increasing awareness
of the benefits of taking action to promote sexual health and reducing negative outcomes. Involve individuals
in the decision-making process so their values, needs and concerns are integrated in the effort to avoid being
pressured into unwanted sexual activity.895
The unique sexual health education needs
of specific “hard-to-reach” groups are not
being met.
Ensure that educational material and programs address the needs of “hard-to-reach” groups
such as new immigrants, First Nations, Inuit and Métis communities, or individuals who have experienced
sexual coercion or abuse.896 Encourage coordination and collaboration among federal, provincial and local
agencies providing these services. Address the sexual health education needs of lesbian, gay, bisexual,
trans-identified, two-spirited or queer people.897
Behavioural/psycho-social factors may
predispose people to engage in risky
sexual behaviours. These include lack of
confidence and low self-worth, past abuse,
abusive relationships and mental illness.
Provide programs to address low self-esteem and depression, including psychotherapy, counselling
and activities to help individuals connect with their family, school, community activities or volunteer work.
Offer prevention programs for illicit drug use, which is associated with risky sexual behaviour.898
Promote strategies to prevent dating violence and sexual abuse. Dating violence can lead to
unwanted sexual activity, which can lead to sexually transmitted infections and unplanned pregnancy.
Strategies include identifying those at risk for sexual violence (e.g., history of abuse in the family, low
self-esteem) and educating teens that abusive behaviour should not be considered the norm.
Lack of access to contraception. If young
people cannot afford contraception or do not
know where to get it without embarrassment,
they may forego contraception.
Ensure access to contraception, especially for people who may not have regular access to primary
care. Some health clinics provide free contraception (e.g., birth control pills) to those who cannot afford it
and/or those who may not feel comfortable accessing it because of cultural reasons.
Unknown spread of infection in the
community. Infections that remain undetected
will be spread further. Infections could also
remain undetected if persons diagnosed with
infections are reluctant to tell healthcare
providers who their sexual partners have been.
Without that information, public health officials
can’t track down partners to have them tested.
Ensure young women have regular pelvic exams to screen for sexually transmitted diseases
along with Pap tests (see section 9.4 for specific ideas).
Deliver treatment and follow-up for people with sexually transmitted infections and their sexual
partners to reduce further spread of infection.899 Strategies to encourage people to name sexual partners
include emphasizing the importance of contact tracing, respecting any wishes for anonymity, and listening to
and addressing any concerns about possible violence or retribution if reporting of partners takes place.
What is Ontario doing?
t .
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at highest risk or those affected by HIV/AIDS. Anonymous HIV testing, point-of-care HIV testing and prenatal HIV testing are available in communities across Ontario. Seventeen HIV clinics across the province provide multi-disciplinary care for people living with HIV/AIDS, and two housing
programs — Casey House and Fife House — offer supportive housing and hospice care.900
t 5IF"*%44FYVBM)FBMUI*OGP-JOFQSPWJEFTQSPWJODFXJEFJOGPSNBUJPODPVOTFMMJOHBOESFGFSSBMGPSJOEJWJEVBMTXIPBSFTFFLJOHIFMQ901
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transmitted infections and promote healthy sexuality for priority populations, cases and contacts. Under the Ontario Public Health Standards, the
board is required to provide clinical services to priority populations, contraceptives, pregnancy tests, comprehensive pregnancy and post-abortion
counsellings, free harm-reduction supplies and other services related to sexually transmitted infections and blood-borne infections.902
105
9. Focused on population health
9.4
Preventive measures
Preventive measures contribute to keeping the population healthy. For example, vaccinations protect against infections and screening tests
can detect diseases early so they can be treated before they become more severe or incurable.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Flu vaccinations for everyone,
especially the elderly.
Without protection from flu vaccinations, more Ontarians will be infected with
influenza, which can lead to hospitalization and deaths in a proportion of ill
people,903 and Ontario will incur increased healthcare costs.
Ontario’s 13 million residents,
especially the elderly and people
with chronic diseases.
Screening for breast, cervical
and colorectal cancers (mammography, Pap test and fecal
occult blood test, respectively)
for everyone eligible.
Without cancer screening, more Ontarians will experience premature death904, 905
and suffering caused by the treatment of advanced cancers, and Ontario will
incur increased healthcare costs and the economic burden of lost productivity.
Ontario’s residents who are at risk
for breast cancer (women aged 50
to 69), cervical cancer (women to
age 69) and colorectal cancer (men
and women aged 50 to 74). Within
a lifetime, one in nine women get
breast cancer 906 and one in 15 men
and women get colon cancer. 907
Screening for osteoporosis for
everyone eligible.908
Without osteoporosis screening, more Ontarians will experience fractures that
may cause disability, pneumonia, death, hospitalization and/or admission to longterm care (LTC) homes, and Ontario will incur increased healthcare costs.909, 910
Ontario’s women over age
55 and elderly men with certain
risk factors.
Value
Percentage of the
population aged
65 and over who
reported having a flu
shot in the year prior
to the survey
72%*
Time trends & comparisons
45
BETTER
0
2001
67%**
2009
50
BETTER
0
2005
73%***
Nearly three-quarters of adult women had a Pap test in the
previous three years. There has been minimal change in the
last seven years.
There is room for improvement in both areas. Ideally, nearly
all eligible women should have these tests.
50
BETTER
0
35%*
2001/03
2007/09
100
Percent
Percentage of people
aged 50 to 74 who
reported having a
fecal occult blood test
(FOBT) within a twoyear period
2009
100
Percent
Percentage of Ontario
women aged 20 to
69 who had a Pap
test within a threeyear period
In 2009, 72% of the population reported getting a flu shot in
the past year. This represents a decrease from 2005, when
Ontario recorded its best performance (78%). Ontario is tied
with Nova Scotia for having the best results in Canada,911
and has rates similar to the better performers among OECD
countries (UK, Korea and Mexico).912 Places with the best
results are Chile (82%)913 and one region in Nova Scotia
(80%)914. There is still room for improvement.
Approximately two-thirds of women aged 50 to 69 had a
mammogram in the past two years. This has increased by
a tenth over the past seven years.
100
Percent
Percentage of Ontario
women aged 50 to
69 who had a mammogram within a
two-year period
Bottom line
90
Percent
Indicator
50
BETTER
0
2005
2009
More than one in three people aged 50 to 74 received
screening for colorectal cancer with an FOBT test in 2009.
In the last four years, these rates have improved from 21%
to 35%. This change is likely due to Ontario’s Colon Cancer
Check program, which was implemented in 2008.915 Ontario
has seen a steady increase in this indicator since this time
and is progressing towards its target of 40% by 2011.916
Data sources:
*
Canadian Community Health Survey, 2009, calculated by Institute for Clinical Evaluative Sciences (ICES). Self-reported rates tend to overestimate actual rates; therefore, the true rates may be lower.
Ontario Breast Screening Program, Ontario Cancer Registry (OCR), Ontario Health Insurance Plan (OHIP), Registered Persons Database (RPD), 2008–2009, calculated by ICES, provided by Cancer Care
Ontario (CCO).
***
Cytobase, OCR, OHIP, RPD, National Ambulatory Care Reporting System Database, Discharge Abstract Database, 2007–2009, calculated by ICES, provided by CCO.
**
106
9.4 Preventive measures
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Value
Percentage of women
aged 65 who had a
bone mineral densitometry test since
turning 55
81%§
Time trends & comparisons
Bottom line
100
Percent
Indicator
50
BETTER
0
2002/03
Approximately one in five elderly women did not receive
screening for osteoporosis in FY 2009/10. That said, there
has been major improvement over the last seven years,
amounting to a steady increase from 58% to 81% in the
number of older women tested. Progress has slowed in the
past year, and there may still be room for improvement.
2009/10
Data sources:
§
OHIP, Statistics Canada Population Files, RPD, FY 2009/10, calculated by ICES.
Root Cause
Ideas for Improvement
People are unaware of, or forget when, they
need screening.
Develop provincial registries to remind people about routine prevention activities. Currently,
the Ontario Breast Cancer Screening Program917 and ColonCancerCheck918 send written
reminders to people who are due for screening. Research suggests such reminders are
well-received by patients.919, 920 These programs could be expanded to other preventive activities.
People are unaware of the importance of prevention
activities, or overestimate risks (e.g. flu vaccinations).
Launch public awareness campaigns to encourage screening.921 Use different media
(pamphlets, posters, videos, and advertisements) to deliver the message. Use easy-to-understand language tailored to the target population.922
Ethno-cultural barriers.923 Different cultures may associate
examination of sexual organs with shame or embarrassment.
Some cultures may have myths about screening (e.g. Pap
screening is not necessary after childbirth).924 Language
barriers may make it difficult to explain the purpose of the test.
Some cultures separate men and women outside of family.925
Always give patients the choice of a male or female healthcare provider for doing
a preventive health test.
Prepare culturally sensitive educational materials in different languages. Specific
ideas include using credible voices from the target community to deliver the message;
addressing myths directly; and acknowledging feelings of embarrassment while promoting
the benefits of the test.
Low-income and education is associated with lower
rates for prevention activities.
Consider targeted outreach programs. See section 10.1 for details.
Patients avoid having preventive procedures because
they are uncomfortable.
Follow best practices for reducing discomfort of procedures. Explain each step of
the process926 before and again during the procedure to reduce anxiety. For Pap tests,
ensure the speculum is at an appropriate temperature and use padded stirrups or
no-stirrup techniques.927
Healthcare providers have competing demands on their
time and may be too busy or may forget to do preventive screening measures.
Use electronic medical records (EMRs) to generate reminders to call the patient in when
he or she is due for a screening test.928 Use EMR data to provide primary care practices
with feedback on how well they are doing on preventive screening and vaccination.929
Instead of doctors, have other health professionals do preventive screening.
People do not have access to primary care, where many
preventive services are given.
Improve access to primary care (see section 2.2)
Provide access to vaccinations outside primary care offices, such as vaccination
clinics in public health units, workplaces, or public places like shopping malls. Give priority
to high-risk people.
Bring screening to patients. For example, the Ontario Breast Cancer Screening
Program has a van that serves small communities in northern Ontario.930
What is Ontario doing?
t $
BODFS$BSF0OUBSJPT0OUBSJP$BODFS1MBOoJOEJDBUFTUIBUCZ0OUBSJPXJMMIBWFBOJOUFHSBUFEDBODFSTDSFFOJOHTUSBUFHZ
for breast, cervical and colorectal cancer, supported by a single information management/information technology system.931
t .0)-5$PGGFSTWBDDJOBUJPOJOGPSNBUJPOGBDUTIFFUTJOMBOHVBHFTPUIFSUIBO&OHMJTIBOE'SFODI932
107
9. Focused on population health
9.5
Deaths and harm that could be avoided by prevention
Many deaths and much harm can be avoided through healthier lifestyles,933 early detection of cancer,934 improved mental health status935
and injury prevention activities.936 By maximizing these opportunities for prevention, Ontario can have a healthier population and reduce
healthcare costs.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
Diseases related to unhealthy habits such as smoking (including
lung cancer and heart attacks) minimized.
Unless Ontario addresses preventable diseases
and injuries, more Ontarians will experience
disability, death, lost time from work and hospitalization, and the province will incur increased
healthcare costs.
Ontario’s 13 million residents.
Suicides and intentional self-harm have a devastating impact that extends beyond the individual
to the family and community. In addition, one
suicide could trigger others.938
Ontario’s 13 million residents,
especially those experiencing
depression,939 schizophrenia940
and substance abuse.941
Preventable injuries (including traffic accidents, falls, sports
injuries and worker injuries) avoided.937
Deaths from cancer where early detection is possible (including
breast and colorectal cancer) minimized.
Suicides and intentional self-harm minimized through community
awareness, early recognition of warning signs and access to
mental health services and social supports.
Lung cancer incidence
per 100,000 people:
Overall
Males
Females
Value
Time trends & comparisons
Bottom line
100
51*
60
44
Rate
Indicator
50
BETTER
0
Percentage of general population
aged 12 and above who report smoking
Relationship between
lung cancer incidence
and smoking rates
1982
80
70
60
50
40
30
20
10
0
2007
In 2007, approximately one in 2,000 Ontarians developed
lung cancer. Incidence rates among men have declined
dramatically in the last three decades. Among women, there
was a gradual increase from 1982 to 1998 but rates have
been stable since then. The overall decrease in lung cancer
is likely due to declines in smoking (see section 9.1), but
there is still major room for improvement as smoking has
not yet been eliminated.
There is a strong relationship between smoking and lung
cancer. For every 5% increase in the percentage of people
who smoke within a LHIN, there is an associated increase in
the rate of lung cancer incidence of 10 per 100,000 people
within the same LHIN.
0
5
10
15
20
25
30
Lung cancer incidence per 100,000
Data sources:
*
Cancer Care Ontario, 2007.
108
In 2007, there were 1,951 deaths due to breast cancer in
Ontario. In Ontario, the rate of female breast cancer mortality has decreased over the past two decades, likely due to
better treatments.942, 943
22*
40
19*
Rate
Breast cancer
mortality rate
per 100,000
females
Colorectal cancer mortality rate
per 100,000
people
20
BETTER
0
1982
2007
In 2007, there were more than 3,100 deaths due to colorectal
cancer in Ontario. In the past 25 years, the rate of colorectal
cancer mortality has decreased by 33%. Screening has the
potential to improve survival and further reduce mortality
rates, so there is still room for improvement.
9.5 Deaths and harm that could be avoided by prevention
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Value
Acute myocardial
infarction (AMI)
incidence per
100,000 people
aged 20 and over
197**
Time trends & comparisons
500
BETTER
0
2002/03
Rate
8.0***
12
3.9
350
300
250
200
150
100
50
0
0
5
10
15
20
25
30
AMI incidence per 100,000 population
7.5
BETTER
0.0
2000
88§
2007
250
125
BETTER
2002/03
In 2007, approximately 1,000 Ontarians committed suicide.
Suicide rates are three times higher among men than women.
The tracking of suicide is poor, and suicides may be underreported. While Ontario has the second lowest suicide rate
in Canada (the Yukon’s rate being 7.1)944, there has been no
change in the suicide rate in the past seven years. There is
room for improvement in reporting and preventing suicide.
There was just under one emergency department visit
for intentional self-harm per 1,000 Ontarians aged 12 and
older in FY2009/10. Even though there has been a 24%
decrease in this indicator in the last seven years, there is
still room to improve.
2009/10
In FY 2009/10, there were about nine emergency
department visits for injury per 100 Ontarians, and
about four hospitalizations for injury per 1,000 Ontarians.
There has been a minor decrease in these rates over the
past five years. There is still room for improvement.
8,845§
10,000
Rate
Approximately 21,000 Ontarians aged 20 and older were
diagnosed with a heart attack last year. The incidence of
heart attack has decreased by 23% over the past seven
years, and decreases in smoking likely contributed to this
trend. There is still room for improvement; lowering Ontario’s
AMI rate to what has already been achieved in Toronto Central LHIN (149) would create enormous benefits.
The relationship between heart attacks and smoking is
strong. For every 5% increase in the percentage of people
who smoke within a LHIN, there is an associated increase in
the rate of the heart attacks of 50 per 100,000 people within
the same LHIN.
0
Rate of
injury-related
emergency
department
visits per
100,000 people
Rate of
injury-related
hospitalizations
per 100,000
people
2009/10
15.0
Rate
Rate of emergency
department visits for
intentional self-harm
per 100,000 people
aged 12 and over
Percentage of general population aged 12
and above who report smoking
Relationship between
AMI and smoking rates
Rate of intentional
self-harm (suicide)
per 100,000 people:
Overall
Males
Females
Bottom line
1,000
Rate
Indicator
5,000
404§§
BETTER
0
2002/03
2009/10
Data sources:
**
Discharge Abstract Database (DAD), Registered Persons Database (RPD), FY 2009/10, calculated by Institute for Clinical Evaluative Sciences (ICES).
Statistics Canada, CANSIM table 102-0552, Deaths and mortality rate, by selected grouped causes and sex, Canada, provinces and territories, annual.
§
National Ambulatory Care Reporting System Database (NACRS), RPD, FY 2009/10, calculated by ICES.
§§
DAD, NACRS, RPD, FY 2009/10, calculated by ICES.
***
109
9. Focused on population health
9.5
For strategies to avoid deaths or injuries related to unhealthy behaviours (e.g., lung cancer and heart attacks), see section 9.1. For strategies to avoid
deaths related to early detection (e.g., breast cancer), see section 9.4.
Root Cause
Ideas for Improvement
Issue: Suicide or intentional self-harm.
People may not seek help because of stigma
of mental illness. They fear being ostracized
or losing their job if others know they have a
mental illness.
Public anti-stigma campaigns can inform the public that mental health issues are far more common
than they realize and can counter common stereotypes (e.g., that mental health sufferers are dangerous or irresponsible945). One grassroots campaign in the US lobbies local broadcasters and
advertisers to stop using these negative stereotypes.946
Warning signs go unnoticed. Family, friends
and colleagues may not recognize mental health
issues until it is too late.
Develop screening tools to identify risk factors, warning signs and at-risk behaviours. High
risk individuals can then be referred to counselling or other services. Some school-based programs
have trained staff to identify students at risk.947 Similar tools exist for the military.948 Consider other
tools for parents, family members, friends, co-workers, and healthcare providers.949
People have difficulty accessing mental
healthcare. They may not know where to
seek care, wait too long to get into a program,
or get sent to wrong programs before finding
the right one.
Ensure access to a primary care provider (see section 2.2.)
Publicize suicide hotlines and crisis services.
Consider centralized intake programs or a “one-stop-shop” referral system for all mental health and
addictions services within a region. Such programs help match the individual with the most appropriate
service (e.g., psychotherapy, counselling, group therapy, peer support groups or substance abuse
programs) and eliminate the need for individuals to make multiple phone calls to different programs.
This approach successfully reduced wait times for services in Thunder Bay.950
Ensure there are programs designed for vulnerable populations and the capacity for these
programs matches the demand. People at increased risk of suicide include youth,951 the elderly,
victims of abuse, prison inmates, sexual minorities and those who have previously attempted
suicide.952 Aboriginal communities are at particularly high risk.953
Unemployment, poverty or lack of housing
may create stresses that lead to suicide.
Ensure equitable access to social services and case managers. These services can help the
individual find safe, affordable housing, assistance with employment or training, or social assistance.
Social isolation can lead to loneliness and
suicide. Weak communities without a sense of
hope can lead to despair.
Build strong and supportive communities. There is growing evidence that “community engagement” may help reduce suicides.954 Examples in Inuit communities include establishment of anti-suicide
youth associations, community suicide prevention walks, and youths kayaking to peers in other
communities to deliver a “Live Life” message.955
“Copycat suicides.” Cluster suicides have
been noted in adolescents956 and First Nations
communities.
Encourage responsible media coverage; avoid sensationalizing suicides in the media to prevent
copycat incidents.957
110
Ensure community intervention after a suicide occurs. Such interventions may include counselling for community members or use of traditional healers in First Nations communities.958
9.5 Deaths and harm that could be avoided by prevention
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Issue: Injuries.
Sports injuries.
Support sports injury prevention programs.
For example, Think First is a national non-profit organization that works with public health units and
community sports and recreation organizations to help children and youth understand how to prevent
common and serious injuries associated with hockey, cycling, soccer, diving, skiing and snowboarding.959
Consider mandating use of safety equipment.
Falls among the elderly.
See section 4.5 and 4.6 for strategies to reduce the risk of falls in LTC homes, home care and
the community.
People injured on the job.
See section 7.3 for change ideas related to healthy work environments.
Traffic-related injuries.
Promote safe driving through awareness campaigns and public policy. Enforce or strengthen
existing traffic safety laws that target drinking and driving960, using cell phones while driving
and improper use of car seats for infants and children. Better municipal planning can decrease
traffic-related injuries, by building roads with traffic-calming features in areas with heavier
pedestrian traffic.961
Assaults.
Help healthcare providers identify people at risk of intimate partner violence. While there is
debate among experts on how frequently this should be done,962 healthcare workers may ask brief
questions during routine physicals and consider using certain assessment tools for people at higher
risk.963, 964, 965, 966 Ensure healthcare providers are aware of and refer individuals to community
supports when violence has been detected.
Ensure safety for workers at risk of assault (e.g. cab drivers, delivery persons, healthcare
workers). This includes safety training, access to panic buttons, or special equipment (e.g. physical
barriers in cabs).
Accidental poisonings.
Promote child safety during primary care visits and during vaccination of infants (see section 9.2).967
What is Ontario doing?
t $
BODFS$BSF0OUBSJPT0OUBSJP$BODFS1MBOoBJNTCZUPEFWFMPQBOJOUFHSBUFEDBODFSTDSFFOJOHTUSBUFHZGPSCSFBTUDFSWJDBM
and colorectal cancer, supported by a single information management/information technology system, and to provide primary care providers with
reports, tools, mentorship and supports to enhance their screening performance.968
111
10. Equitable
10.1
Primary care — access and effectiveness
People should be able to access the healthcare services they need without any difference based on their income, education level, age, sex,
location, or whether they are immigrants or born in Canada. This section examines whether healthcare in Ontario is equitable, with a focus
on access to primary care, appropriate chronic disease monitoring, unhealthy behaviour, preventive measures, and diseases that could be
avoided with a population health focus.
What do Ontarians want?
What if it doesn’t happen?
Who benefits most?
No barriers accessing
high-quality care because
of income, education level,
age, sex, urban or rural
residence, or whether someone is an immigrant or born
in Canada. All Ontarians living
healthy lifestyles, regardless
of who they are.
Health can deteriorate when people who are disadvantaged in society do not get the services
they need or engage in unhealthy behaviours. A vicious circle may start as declining health
leads to lower income or under-employment and these people may become more disadvantaged
and reliant on social assistance. This is bad for the individual and also for family members and
dependents. Employers may be affected, too, as worsening workforce health leads to more
sick time and/or staff turnover.969
Ontario’s 13 million
residents.
Indicator
Comparisons
Income
Sex
Location
Age
Immigrant Status
20
15.2
Percent
Access to
primary care:
– Percentage of
adults without a
regular doctor*
Education
Bottom line
10
9.5
7.2 6.9
5.2 5.1
BETTER
8.2
6.4 6.6
6.1
7.1
6.4
4.8
5.4
The elderly are more likely to have
a regular doctor than adults aged
18 to 64 years. Given that the
elderly have greater healthcare
needs, it is encouraging to see that
they are more likely to have access
to primary care.
3.3
0
Low Med High
<HS HS
PSE
F
M
Urb Rur
18– 65+
64
6.5% of adults in Ontario were without a regular doctor in FY 2009/10.
Those most likely not to have a
regular doctor are low-income
individuals, men and immigrants
who arrived in Canada in the last
10 years.
Can 10+ 0–9
Born
There were no significant differences in access to primary care
by education or urban versus
rural location.
100
BETTER
64.7
Percent
Monitoring of
chronic disease:
– Percentage of
patients with diabetes who, in the past
12 months, had an
eye exam**†
50
0
49.9 51.1 51.8
52.250.0
50.5
54.8
40.5
Low Med High
F
M
Urb Rur
20– 65+
64
52.1
47.3
<50% >=50%
In FY 2009/10, only about half
(51%) of adults with diabetes in
Ontario had an eye exam within
the past year. Those most likely
not to have had an eye exam were
people aged 20 to 64. The rate
of eye exams was slightly lower
among low-income individuals,
men, and those living in urban
areas and in high immigrant
population neighbourhoods.
Legend: Low = 1st income quintile; Med = 3rd income quintile; High = 5th income quintile. HS = high school graduate; <HS = less than high school graduate; PSE = at least some post-secondary education.
F = female; M = male. Urb = urban; Rur = rural. Can Born = Canadian-born. 0-9 = recent immigrant in Canada for nine years or less; 10+ = immigrant in Canada for 10 years or more. Low Imm = low immigrant
population area; High Imm = high immigrant population area.† For this indicator, income is not measured directly, but inferred from the average income in one’s immediate neighbourhood corresponding to
the postal code. A high immigrant population area was defined as one where the neighbourhood, or census dissemination area (DA) surrounding one’s postal code, showed the immigrant population at more
than 50% of residents, as reported to Census Canada.
Data sources: *Primary Care Access Survey, FY 2009/10, provided by Institute for Clinical Evaluative Sciences (ICES).
**Ontario Diabetes Database, Ontario Health Insurance Plan, Registered Persons Database, FY 2009/10, calculated by ICES.
112
10.2 Unhealthy behaviour
HOSPITAL
10.2
Unhealthy behaviour
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Comparisons
Income
40
20
Sex
Location
Age
Immigrant Status
In 2009, 19% of Ontarians smoked, 18% were
obese, 49% were physically inactive, 56% had inadequate fruit and vegetable intake and 22% had binge
drinking episodes.
34.9
26.5
26.1
Percent
Percentage
of the population who
smoke*
Education
Bottom line
23.6
21.5
19.7
15.3
13.3
21.9
21.3
17.9
15.5
12.9
9.0
7.9
6.0
0
<HS HS
PSE
F
M
Urb Rur
12– 18– 65+
17 64
Can 10+ 0–9
Born
40
Percent
Percentage of the
population
who are
obese*
Low Med High
BETTER
20
18.319.0
16.1
22.9
21.0
17.3
19.0
16.8
22.1
17.4
Having a lower level of education is associated
with worse results for all health behaviours except
heavy drinking.
20.7
17.5
20.6
12.6
Living in a rural area is associated with higher rates
of smoking, obesity and binge drinking, but lower
rates of physical inactivity.
11.9
BETTER
0
<HS HS
PSE
F
M
Urb Rur
20– 65+
64
Can 10+ 0–9
Born
100
70.2
61.4
Percent
Percentage of the
population
who are
physically
inactive*
Low Med High
50
57.8
48.7
50.2
58.9
53.3
45.3
50.0
44.3
34.4
49.7
59.3
57.7
29.4
<HS HS
PSE
F
M
Urb Rur
12– 18– 65+
17 64
Can 10+ 0–9
Born
50
62.4
56.0
50.4
66.8
62.8
52.3
61.3
56.2
51.2
56.6
57.4
54.3
51.6
If health professionals wish to direct their health
promotion efforts towards those groups most likely to
have any of these unhealthy behaviours, they should
target the following:
57.4 56.9
46.7
BETTER
0
Low Med High
<HS HS
PSE
F
M
Urb Rur
12– 18– 65+
17 64
t1IZTJDBMJOBDUJWJUZ‰-FTTUIBOIJHITDIPPMFEVDBUJPO
low income, immigrants, aged 65+, women; note that
seniors are most likely to be inactive, but it is also
important to target physical inactivity at earlier ages
to maximize the benefits of exercise over a lifetime
28.9
20
20.3
19.9
24.8
23.4
19.3
20.1
20.5
17.1
23.7
23.7
18.4
14.4
13.0
8.9
5.9
0
Low Med High
<HS HS
PSE
F
M
Urb Rur
12– 18– 65+
17 64
t4NPLJOH‰-FTTUIBOIJHITDIPPMFEVDBUJPOMPX
income, rural residents, aged 18 to 64 years, men,
born in Canada
t0CFTJUZ‰-FTTUIBOIJHITDIPPMFEVDBUJPOSVSBM
residents, aged 65+, born in Canada
Can 10+ 0–9
Born
40
Percent
Percentage of the
population
who have
had binge
drinking
episodes*
Immigrants are less likely to smoke, be obese and
engage in binge drinking but more likely to be
physically inactive. Fruit and vegetable intake is better
among immigrants in Canada for less than 10 years.
SUMMARY:
100
Percent
Percentage
of the population with
inadequate
fruit and
vegetable
intake*
Low Med High
Adults aged 18 to 64 are more likely to smoke and
drink heavily than older adults and adolescents. Elderly
individuals are more likely to report being obese and
physically inactive, but less likely to report having an
inadequate fruit and vegetable intake and drinking
heavily. There is no difference in fruit and vegetable
intake by age group.
Compared to women, men are more likely to smoke,
have inadequate fruit and vegetable intake and be
heavy drinkers, but less likely to be physically inactive.
45.2
BETTER
0
The lower the income, the higher the likelihood to
smoke, be physically inactive and have inadequate
fruit and vegetable intake. There was little difference
by income group in obesity, except that the high
income group had lower obesity rates than everyone
else. Unlike other health behaviours, the likelihood of
binge drinking increases with higher income.
BETTER
Can 10+ 0–9
Born
t*OBEFRVBUFGSVJUBOEWFHFUBCMFJOUBLF‰-FTTUIBO
high school education, low income, men
t#JOHFESJOLJOH‰.FOSVSBMSFTJEFOUTCPSOJO
Canada, aged 18 to 64 years, high income
Legend: Low = 1st income quintile; Med = 3rd income quintile; High = 5th income quintile. HS = high school graduate; <HS = less than high school graduate; PSE = at least some post-secondary education.
F = female; M = male. Urb = urban; Rur = rural. Can Born = Canadian-born. 0-9 = recent immigrant in Canada for nine years or less; 10+ = immigrant in Canada for 10 years or more.
Data source: *Canadian Community Health Survey, 2009, calculated by Institute for Clinical Evaluative Sciences.
113
10. Equitable
10.3
Preventive measures
Indicator
Comparisons
Income
Age
Immigrant Status
68.6
66.0 67.2
64.6
Low Med High
73.2
72.9 72.8
73.3
68.6
78.7
73.2
65.1
BETTER
50
Low Med High
67% of eligible women had had
a mammogram in the last two
years, 73% of eligible women had
had a Pap test in the last three
years and 35% of eligible adults
had had a fecal occult blood test
(FOBT) in the last two years.
The lower the income, the less
likely a woman was to have had
a mammogram or Pap test. No
significant differences were seen
in FOBT rates by income.
50– 55– 60– 65–
54 59 64 69
100
Percent
BETTER
50
0
Women aged 60 to 69 years were
less likely to have a Pap test.
Those aged 50 to 64 years were
less likely than seniors aged 65
to 74 to have an FOBT. In both
cases, this age gap could be due
to a mistaken belief that the test
is not as important at that age.
No major differences were seen
in mammography use by age.
20– 30– 40– 50– 60–
29 39 49 59 69
100
BETTER
Percent
Percentage of people
aged 50 to 74 who
reported having a
fecal occult blood
test (FOBT) within a
two-year period***,§
Location
71.2
66.8
58.9
0
Percentage of
women aged 25 to
69 who had a Pap
test within a threeyear period**†
Sex
100
Percent
Percentage of women
(aged 50 to 69) who
had a mammogram
within a two year
period*†
Education
Bottom line
50
35.8
35.2
33.7
36.5
34.0
30.8
35.6 34.7
35.5 32.8
41.4
32.9
35.3 34.9
††
0
§
Low Med High
<HS HS
PSE
F
M
Urb Rur
50– 65–
64 74
Can 10+ 0–9
Born
Legend: Low = 1st income quintile; Med = 3rd income quintile; High = 5th income quintile. HS = high school graduate; <HS = less than high school graduate; PSE = at least some post-secondary
education. F = female; M = male. Urb = urban; Rur = rural. Can Born = Canadian-born. 0-9 = recent immigrant
in Canada for nine years or less; 10+ = immigrant in Canada for 10 years or more.
†
For these indicators, income is not measured directly, but inferred from the average income in one’s immediate neighbourhood corresponding to the postal code. A high immigrant population area
was defined as one where the neighbourhood, or census dissemination area (DA) surrounding one’s postal code, showed the immigrant population at more than 50% of residents, as reported to
Census Canada.
††
Data suppressed for this category because of small sample size.
Data sources:
*Ontario Breast Screening Program, Ontario Cancer Registry (OCR), Ontario Health Insurance Plan (OHIP), Registered Persons Database (RPD), FY 2009/10, calculated by
Institute for Clinical Evaluative Sciences (ICES).
**OCR, OHIP, RPD, National Ambulatory Care Reporting System Database, Discharge Abstract Database, FY 2009/10, calculated by ICES.
***Canadian Community Health Survey, 2009, calculated by ICES. Self-reported rates tend to overestimate actual rates; therefore, the true rates may be lower.
114
10.4 Diseases that could be avoided with a population health focus
HOSPITAL
10.4
Diseases that could be avoided with a
population health focus
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Indicator
Comparisons
Income
Age
Immigrant Status
655
400
233 205
172
0
Low Med High
262
235
214
198
138
153
92
F
M
Urb Rur
BETTER
20– 65+
64
Rural residents are at greater risk of worse outcomes
for all four measures. People living in areas with a
large immigrant population are less likely to have
worse outcomes.
131
110
106
80
96
96
86
77
72
63
53
20
0
Low Med High
F
M
Urb Rur
12– 18– 65+
17 64
In FY 2009/10, there were 197 new heart attacks,
88 emergency department visits for intentional self-harm,
8,845 emergency department visits for injuries and
404 hospitalizations for injuries, per 100,000 people.
As income rises, the chance of experiencing any of these
events decreases steadily. This is particularly noticeable
for emergency department visits for intentional self-harm
where the rate for those with the lowest income is more
than twice the rate for those with the highest income.
Men are at a greater risk of having a heart attack or
an injury, but women are at greater risk of having an
emergency department visit for intentional self-harm.
<50% >=50%
152
160
Rate
Rate of
emergency
department
visits for intentional self-harm
per 100,000
people aged
12 and over**†
Location
800
Rate
Acute myocardial
infarction (AMI)
incidence per
100,000 people
aged 20 and
over*†
Sex
Bottom line
BETTER
<50% >=50%
Adolescents (aged 12 to 17) are more likely to have
an emergency department visit for an injury, but the
elderly are more likely to be hospitalized for an injury.
Also, adolescents are much more likely than adults
(aged 18 to 64) to have an emergency department visit
for intentional self-harm.
SUMMARY:
16,000
Rate
Rate of
injury-related
emergency
department
visits per
100,000
people*†
If health professionals wish to direct their health promotion
efforts towards those groups most likely to have worse
outcomes, they should target the following:
14,544
9,506
8,788
8,223
8,000
11,309
8,028
9,918
8,140
7,728
8,833
9,690
t".*IFBSUBUUBDL
JODJEFODF‰.FOSVSBMSFTJEFOUT
low income, low immigrant population neighbourhoods
5,555
BETTER
0
Rate of
injury-related
hospitalizations
per capita*†
Low Med High
F
M
Urb Rur
Rate
1,400
700
0
12– 18– 65+
17 64
t&NFSHFODZEFQBSUNFOUWJTJUTGPSJOKVSJFT‰3VSBM
residents, adolescents, men, low immigrant population
neighbourhoods, low income
<50% >=50%
t)PTQJUBMJ[BUJPOGPSJOKVSJFT‰&MEFSMZSVSBMSFTJEFOUT
low income, low immigrant population neighbourhoods
1,274
477
t*OUFOUJPOBMTFMGIBSN‰"EPMFTDFOUTMPXJODPNF
rural residents, women, low immigrant population
neighbourhoods
529
386
361
Low Med High
394 403
F
M
388
Urb Rur
433
281
191
12– 18– 65+
17 64
273
BETTER
<50% >=50%
Legend: Low = 1st income quintile; Med = 3rd income quintile; High = 5th income quintile. F = female; M = male. Urb = urban; Rur = rural. Low Imm = low immigrant population area;
High Imm = high immigrant population area.
†
For these indicators, income is not measured directly, but inferred from the average income in one’s immediate neighbourhood corresponding to the postal code. A high immigrant population area
was defined as one where the neighbourhood, or census dissemination area (DA) surrounding one’s postal code, showed the immigrant population at more than 50% of residents, as reported to
Census Canada.
Data sources:
*Discharge Abstract Database, National Ambulatory Care Reporting System Database (NACRS), Registered Persons Database (RPD), FY 2009/10, calculated by Institute for Clinical
Evaluative Sciences (ICES).
**NACRS, RPD, FY 2009/10, calculated by ICES. Because of data limitations, it was not possible to measure education differences at the same time as income for this
set of indicators.
115
10. Equitable
10.4
Root Cause
Ideas for Improvement
Low-income persons face cost barriers.
They cannot afford gym memberships or sports
programs, have difficulty paying out-of-pocket
costs (e.g. transportation), and may believe that
healthy eating is too expensive.
Promote low-cost healthy foods (see section 9.1 for list).
Consider offering transportation and daycare for health promotion programs, or bring the
program to the individual.
Encourage access to low- or no-cost sports and recreation programs970 and keep physical
education in the school curriculum.971
Promote low-cost access to nutritious foods, such as the Good Food Box, a volunteer-run food
distribution system operating in communities throughout the province.972
Consider offering free nicotine replacement products to low-income persons.
Day-to-day survival is the main concern.
Peoples’ health concerns may be outweighed
by priorities such as finding food, shelter,
paying bills or escaping abusive situations.
Ensure timely access to social workers and case management. Arrange supportive housing,
employment counselling, skills development, or shelter for those suffering from abuse.
Low-income persons may not access
primary care and health promotion
programs, because they are unaware of
them, or are distracted by day-to-day survival.
Design outreach programs to make participation easy. Bring primary care centres and health
promotion activities deep into the communities being served — at community centres, malls, and
wherever else people naturally congregate.973 Develop models of care which house primary care
and social services in the same place,974 as many community health centres have done.975, 976
Poverty generates chronic stress,977
and people may cope through unhealthy
but pleasurable activities like smoking.978
Consider offering stress management therapies for low-income persons. While evidence in the
scientific literature is limited, methods that have been tried include meditation,979 exercise relation and
creative activities.980
Low education or literacy level may lead
to low level of knowledge about diet or
healthy living.
Simplify and tailor learning materials. Ensure material uses graphics for those with low literacy,
simple English or local slang, or the languages spoken by targeted communities. Keep instructions
simple and step-by-step.981
Healthcare providers can provide or refer for counselling on healthy diet or lifestyle. Group
sessions allow people with similar life challenges to support each other in their learning.
Consider distributing healthy, low-cost shopping lists and offering supermarket tours,982 where
individuals can learn where to find low cost, healthy foods, identify unhealthy foods, search for bargains,
and read food labels. Consider cooking classes983 for underprivileged persons on healthy cooking.
People may lack skills, motivation or
confidence to change health habits.
Promote patient self-management,984, 985, 986, 987 where patients learn about their condition and
are coached into setting their own reasonable goals for improvement that fit with their lifestyle
(see section 9.1).
Disadvantaged persons may live in
unhealthy neighbourhoods where people
do not feel safe walking about to get exercise,
or cannot get to supermarkets easily.
Make neighbourhoods safe. Increase foot patrols of police or security personnel, or organize group
walking or physical activities. Work with municipal officials to ensure safe, well-lit paths for walking.
There is a local culture of unhealthy
habits. Smoking or dangerous activities may
be considered “normal”989 within a community.
Organize community-wide healthy living events (e.g. community walks or sporting events).
Identify healthy role models for disadvantaged children. Identify “positive deviants” — individuals
or groups who have good health who live within unhealthy communities; find out their secret to
success and spread it widely.990
116
Design communities for healthy living, by zoning that encourages walking to shops and supermarkets. Such neighbourhoods tend to have better health outcomes.988
10.4 Diseases that could be avoided with a population health focus
HOSPITAL
LONG-TERM CARE
HOME CARE
PRIMARY CARE
Root Cause
Ideas for Improvement
Women in certain cultures may be reluctant
to undergo mammography and Pap tests
(see section 9.4).
Develop culturally sensitive learning materials in the language of the target audience, which
address myths about screening, emphasize the importance of the test, and use credible spokespersons from the culture (see section 9.4).
Some rural activities are dangerous.
Farming991 and rural recreational activities like
all-terrain vehicles (ATVs)992 have high injury rates.
Identify common farming accidents (tractor rollovers, gas poisoning, and power takeoff
entanglements) and promote specific measures to prevent them.993 Encourage use of safety
gear (e.g. helmets) and proper training when using recreational vehicles like ATVs.
What is Ontario doing?
t .
0)-5$IBTEFWFMPQFEB)FBMUI&RVJUZ*NQBDU"TTFTTNFOU5PPM)&*"
UPBEWBODFIFBMUIFRVJUZJOUFHSBUJPOJOIFBMUIDBSFQPMJDZQMBOOJOH
and decision-making.994 HEIA maps the unintended potential health impacts of a policy, program or project on specific population groups
(e.g., Aboriginal, francophone, gender, income, race, and geography) and prompts the assessor to adjust the initiative to mitigate negative
impacts and maximize positive impacts on impacted populations. MOHLTC began implementation in 2009 and HEIA pilots have been conducted
within MOHLTC and in three of the 14 LHINs.
117
11. LHIN Analyses
11
LHIN analyses
In this chapter, we present data on differences between each LHIN and the provincial average, for selected indicators where data were
available. In the first set of tables, we present data for each LHIN, identifying where its performance is better or worse than average. We
also include data over time for select indicators*. In the table at the end of this chapter, we present more detailed results for each indicator
and each individual LHIN. Yellow shading shows that the LHIN was significantly better than the provincial average, while blue shading shows
the LHIN is worse than average.
Differences were considered significant if they were both statistically significant** and clinically significant. We used the following guidelines
to define significant differences:
Type of indicator
Guidelines for a clinically significant
difference between a LHIN and the
provincial average
Wait times
Relative difference of 25%
Rate of a serious adverse outcome
Relative difference of 25%
Percentage adoption of a best practice (process measure,
often with a target of 100%)
Absolute difference of 5%***
Patient experience variable (e.g., percentage satisfied with x)
Absolute difference of 5%
Abbreviations used in this chapter are as follows:
ALC
= alternate level of care (in this case, a hospital bed occupied by someone who could be better served in a different setting, such as a
long-term care home)
AMI
= acute myocardial infarction (heart attack)
CHF
= congestive heart failure
COPD = chronic obstructive pulmonary disease (emphysema or chronic bronchitis)
ED
= emergency department
FOBT = fecal occult blood test
LHIN = local health integration network
LTC
= long-term care home
The following tables show some areas in which LHINs can improve. Please refer to the table at the very end of this chapter for more details on
selected indicators where data was available.
* Only changes in LTC waits of greater than 1 week and changes of ALC >1% are commented on.
** For some indicators where data were obtained from other parties, confidence intervals were not available, but statistical significance was inferred based on estimates of the
sample size and assumptions about the probability distribution of the variable. See the technical appendix to this document at www.hqontario.ca for more details.
*** In some instances where the rate is high (e.g. 96%) but the target is clearly 100%, the difference is treated as defect (e.g. 4%) and a relative difference of 25% is considered
significant (in this example, a difference greater than plus or minus 1% would be considered significant).
118
119
11. LHIN Analyses
ERIE ST. CLAIR LHIN
Superior results, no room to improve
t None
Better than average results, still room
to improve
t Shorter waits for a LTC bed, especially for people placed from the community
t Fewer ALC hospital bed days
t Shorter wait times for CT/MRI scans, cancer surgery, cataract surgery and hip and knee replacements
(general surgery waits similar to rest of province)
t More timely home care visits after hospital discharge
Average results, still room to improve
t
t
t
t
t
t
t
t
t
t
Worse than average results, major room
to improve
t Population health - smoking, obesity, physical activity, binge drinking are at provincial average but rates of fruit
and vegetable intake and smoking in pregnancy are worse, and lowest rate in Ontario for breastfeeding
ED wait times (but relatively fast transfer to a bed after admission)
Access to primary care
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
Avoidable hospitalizations (readmissions higher for some conditions, lower for others)
LTC safety and effectiveness (most indicators at provincial average)
Home care safety and effectiveness
Avoidable ED visits by LTC residents
Preventive health screening
Note: Erie-St. Clair has a relatively low supply of family doctors and specialists.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
Overall
No major change
Placement from hospital
Worse by 18 days
Placement from home
Better by 12 days
ALC (from 2008/09 to 2009/10)
No major change
SOUTHWEST LHIN
Superior results, no room to improve
t None
Better than average results, still room
to improve
t
t
t
t
t
Shorter ED wait times
Shorter waits for a LTC bed, especially for people placed from the community
Fewer ALC hospital bed days
Shorter wait times for CT scans, MRI
Lower C-section rates
Average results, still room to improve
t
t
t
t
t
t
t
t
t
Access to primary care
Wait times for most surgeries (except cancer)
Avoidable hospitalizations
Avoidable ED visits by LTC residents
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
LTC safety and effectiveness (most indicators at provincial average)
Home care safety and effectiveness
Preventive health screening
Worse than average results, major room
to improve
t Wait times for cancer surgery
t Population health – smoking and physical inactivity rates are average but worse results for obesity, fruit and
vegetable intake, smoking in pregnancy; higher rates of injury
Note: Southwest LHIN has a relatively high supply of nurses, nurse practitioners and registered practical nurses.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
ALC (from 2008/09 to 2009/10)
120
Overall
No major change
Placement from hospital
No major change
Placement from home
No major change
No major change
11. LHIN Analyses
WATERLOO-WELLINGTON LHIN
Superior results, no room to improve
t None
Better than average results, still room
to improve
t Use of right drugs for hospital patients with AMI, CHF
t Shorter waits for cancer and general surgery, cataract surgeries and hip replacements
t Avoidable ED visits by LTC residents
Average results, still room to improve
t
t
t
t
t
t
t
t
t
t
t
t
Worse than average results, major room
to improve
t Longer waits for a LTC bed, especially for people placed from the community
ED waits – a mixed picture, with longer waits to see a physician but shorter waits for those who are admitted
ALC hospital bed days
Access to primary care
Waits for CT/MRI, cancer surgery, knee replacements
Home care waits
Avoidable hospitalizations (readmissions higher for some conditions, lower for others)
Chronic disease management (diabetes complications, AMI survival)
C-section rates
LTC safety and effectiveness (most indicators at provincial average)
Home care safety and effectiveness
Population health (smoking, obesity, physical inactivity, diet, binge drinking similar to provincial rates)
Preventive health screening
Note: Waterloo-Wellington has a relatively low supply of specialists.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to
2009/10)
Overall
Worse by 26 days
Placement from hospital
Worse by 22 days
Placement from home
Worse by 20 days
ALC (from 2008/09 to 2009/10)
Improved by 2%. (Note that the paradoxical improvement in ALC with worsening
LTC waits may be due to different time periods used for comparisons over time).
HAMILTON-NIAGARA-HALDIMAND-BRANT LHIN
Superior results, no room to improve
t None
Better than average results, still room
to improve
t Access to primary care
Average results, still room to improve
t
t
t
t
t
t
t
t
t
t
Home care waits
Avoidable hospitalizations (most indicators at provincial average)
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
LTC safety and effectiveness
Home care safety and effectiveness
Avoidable ED visits by LTC residents
Population health (most indicators at provincial average)
Preventive health screening (but rates of fecal occult blood testing are lower)
Worse than average results, major room
to improve
t
t
t
t
Longer ED wait times, especially for admitted patients
More ALC hospital bed days
Longer waits for a LTC bed, especially for people placed from hospital
Longer waits for hip and knee replacement and CT/MRI (waits are average for other surgeries, like cancer,
general surgery, cataracts)
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to
2009/10)
Overall
Worse by 34 days
Placement from hospital
Worse by 28 days
Placement from home
ALC (from 2008/09 to 2009/10)
Worse by 46 days
Improved by 3%. (Note that the paradoxical improvement in ALC with worsening
LTC waits may be due to different time periods used for comparisons over time).
121
11. LHIN Analyses
CENTRAL WEST LHIN
Superior results, no room to improve
t Rate of statin use after an AMI surpasses 90% target
Better than average results, still room
to improve
t
t
t
t
Shortest wait for a LTC bed in Ontario (however, lowest rate of people given their first choice of LTC home)
Fewer ALC hospital bed days
Shorter wait times for, general surgery, hip replacement, CT scans
Population health (lower rates of smoking, smoking in pregnancy, binge drinking, inadequate fruit & vegetable
intake; lower rates of injury and self-harm; physical inactivity, however, is worse than average)
Average results, still room to improve
t
t
t
t
t
t
t
Access to primary care
Waits for MRI, cancer surgery, cataract surgery, knee replacement
Home care waits
Avoidable hospitalizations (readmissions higher for some conditions, lower for others)
Chronic disease management (diabetes complications, AMI survival)
LTC safety and effectiveness
Avoidable ED visits by LTC residents
Worse than average results, major
room to improve
t
t
t
t
t
Longer ED wait times
Higher C-section rate for uncomplicated deliveries
Drug safety in LTC (high rates of new starts of antipsychotics, anti-anxiety drugs)
Home care safety and effectiveness
Preventive health screening – worse results for flu shots, mammography and fecal occult blood testing
Note: Central West has a relatively low supply of family doctors, specialists and nurses.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
Overall
No major change
Placement from hospital
No major change
Placement from home
Better by 27 days
ALC (from 2008/09 to 2009/10)
No major change
MISSISSAUGA-HALTON LHIN
Superior results, no room to improve
t None
Better than average results, still room
to improve
t Fewer ALC hospital bed days
t Shorter waits for a LTC bed, for people placed from hospital
t Avoidable hospitalizations – low rates of admission for ambulatory care sensitive conditions and lower readmission rates for AMI, diabetes, GI bleed
t Shorter wait times for hip and knee replacements
Average results, still room to improve
t
t
t
t
t
t
t
t
t
t
t
Worse than average results, major room
to improve
t Population health (most rates at average but lower rate of smoking during pregnancy, breastfeeding right after
birth, inadequate fruit and vegetable intake, and intentional self-harm)
ED wait times
Access to primary care
Waits for surgery and CT/MRI – mostly similar to provincial average, but waits are lower for hip and knee replacement
Home care waits
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
LTC safety and effectiveness (most indicators at average)
Home care safety and effectiveness (most indicators at average)
Avoidable ED visits by LTC residents
Preventive health screening (but worse results on flu vaccination)
Mississauga-Halton has a relatively low supply of specialists and nurses.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
Overall
No major change
Placement from hospital
No major change
Placement from home
ALC (from 2008/09 to 2009/10)
122
Better by 25 days
Improved by 4%
11. LHIN Analyses
TORONTO CENTRAL
Superior results, no room to improve
t None
Better than average results,
still room to improve
t Lower rate of ALC hospital bed days
t LTC safety and effectiveness – average for most indicators but better results on restraint use, worsening depression/
anxiety, and lower rate of new prescriptions for antipsychotics
t Population health (lowest rate of smoking; lower obesity; higher rates of breastfeeding)
t Shorter wait times for hip and knee replacements
Average results, still room
to improve
t
t
t
t
t
t
t
t
t
t
t
Worse than average results,
major room to improve
Wait time for a LTC bed
Access to primary care
Waits for CT, MRI
Waits for general surgery, cataract surgery
Home care waits
Avoidable hospitalizations – rate of hospitalizations for ambulatory care sensitive conditions similar to provincial
average; rates worse than average for COPD, stroke, diabetes readmissions
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
Avoidable ED visits by LTC residents
Preventive health screening – most rates at average but mammography screening, fecal occult blood test lower than average
t Longer ED wait times
t Longer waits for cancer surgery
t Home care safety and effectiveness – average for most indicators but worse results for worsening activities of daily
living, depression and worsening cognitive function
t Highest incidence of HIV infection
Note: Toronto Central has a relatively high supply of family doctors and nurses, and the highest concentration of specialists in Ontario.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
ALC (from 2008/09 to 2009/10)
Overall
Worse by 20 days
Placement from hospital
Worse by 10 days
Placement from home
Worse by 48 days
No major change
123
11. LHIN Analyses
CENTRAL LHIN
Superior results, no room to improve
t None
Better than average results, still
room to improve
t Avoidable hospitalizations – lowest rate of admissions for ambulatory care sensitive conditions in Ontario
t LTC safety and effectiveness (lower restraint use; lower rate of worsening of activities of daily living,
pain, or depression / anxiety)
t Shorter wait times for surgery, including cataract, cancer, hip and knee replacements and general surgeries
t Population health – lower rates for smoking in pregnancy, obesity, binge drinking; lower rates for
self-harm and injuries
Average results, still
room to improve
t
t
t
t
t
t
t
t
t
t
t
Worse than average results, major
room to improve
t Longer ED waits, especially for admitted patients
ALC hospital bed days
Waits for a LTC bed
Wait times for CT/MRI
Access to primary care
Home care waits
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
Home care safety and effectiveness (better than average results for weight loss; worse results for depression)
Avoidable ED visits by LTC residents
Preventive health screening (average for most indicators but higher rates of Pap screening)
Note: The Central LHIN has a relatively low supply of specialists and nurses.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09
to 2009/10)
Overall
Better by 8 days
Placement from hospital
Better by 8 days
Placement from home
Better by 20 days
ALC (from 2008/09 to 2009/10)
Worsened by 2%. (Note that the paradoxical increase in ALC with improvement in LTC waits
may be due to different time periods used for comparisons over time).
CENTRAL EAST LHIN
Superior results, no room to improve
t None
Better than average results, still room to improve
t Shorter wait times for general surgeries
Average results, still room to improve
t ALC hospital bed days
t Wait time for a LTC bed is similar to provincial average, but waits are longer than average for people being
placed from hospital
t Access to primary care
t Waits for CT/MRI and surgery (with shorter waits for general surgery, longer waits for cataract surgery)
t Home care waits
t Avoidable hospitalizations (most indicators at provincial average; lower readmission rate for stroke and diabetes)
t Chronic disease management (diabetes complications, AMI survival)
t Use of right drugs for hospital patients with AMI, CHF
t C-section rates
t LTC safety and effectiveness
t Home care safety and effectiveness
t Avoidable ED visits by LTC residents
t Population health (smoking, obesity at provincial average but higher than average rate of physical inactivity)
t Preventive health screening (but lower rate of fecal occult blood testing)
Worse than average results, major room
to improve
t Longer ED wait times, especially for admitted patients
t Relatively low supply of specialists and nurses
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
ALC (from 2008/09 to 2009/10)
124
Overall
Worse by 26 days
Placement from hospital
Worse by 26 days
Placement from home
Worse by 8 days
Worsened by 3%
11. LHIN Analyses
SOUTHEAST LHIN
Superior results, no room to improve
t None
Better than average results, still
room to improve
t ED wait times
t Access to primary care
t Shorter wait times for cataract surgery
Average results, still room to improve
t
t
t
t
t
t
t
t
t
t
t
t
Worse than average results, major
room to improve
ALC hospital bed days
Waits for a LTC bed
Waits for surgery is at average, but long waits for MRI scans
Avoidable hospitalizations (readmissions higher for some conditions, lower for others)
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
LTC safety and effectiveness (most indicators similar to provincial average; worse rates for bladder infections,
restraint use, use of new antipsychotics)
Home care safety and effectiveness (most indicators similar to provincial average)
Avoidable ED visits by LTC residents
Supply of family doctors, specialists and nurses
Preventive health screening (most indicators similar to provincial average, but with higher rates of Pap tests)
t Longer waits for MRI
t Home care waits
t Population health (higher rate of smoking but less physical inactivity; higher rates of self-harm, injury-related
ED visits)
Note: The Southeast has a relatively higher supply of nurses and nurse practitioners and an average supply of doctors.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
ALC (from 2008/09 to 2009/10)
Overall
No major changes
Placement from hospital
Better by 23 days
Placement from home
No major changes
No major changes
125
11. LHIN Analyses
CHAMPLAIN
Superior results, no room to improve
t None
Better than average results, still
room to improve
t Shorter wait times for MRI scans
t Avoidable hospitalizations (rate of admission for ambulatory care sensitive conditions slightly lower than
average; readmissions lower for AMI, asthma, stroke and GI bleed)
Average results, still room to improve
t
t
t
t
t
t
t
t
t
Worse than average results, major
room to improve
t Longer waits for hip and knee replacement, cataract surgery, general surgery
t Longest wait time for a LTC bed in Ontario, for people placed from the community. (Wait times for people
placed from hospital are close to the provincial average)
t Longer time to home care visit after hospital discharge
t Second-highest rate of HIV incidence in Ontario (after Toronto Central)
ALC hospital bed days
ED wait times
Access to primary care
Wait times for CT scans, cancer surgery
Avoidable ED visits by LTC residents
Chronic disease management (diabetes complications, AMI survival)
Use of right drugs for hospital patients with AMI, CHF
C-section rates
LTC safety and effectiveness (average for most indicators; worse results for restraint use but better (lower) results
for new starts of anti-anxiety drugs)
t Home care safety and effectiveness (average for most indicators)
t Population health (average results for smoking, obesity; higher rate of binge drinking but lower rate of physical
inactivity; higher rate of breastfeeding)
t Preventive health screening (average for most indicators but better results for Pap screening)
Note: Champlain has a relatively high family physician and specialist supply.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
Overall
Better by 28 days
Placement from hospital
Worse by 11 days
Placement from home
ALC (from 2008/09 to 2009/10)
Worse by 13 days
Worsened by 2%
NORTH SIMCOE MUSKOKA LHIN
Superior results, no room to improve
t None
Better than average results, still room to improve
t Shorter ED waits
Average results, still room to improve
t ALC hospital bed days
t Access to primary care (% of population without a family doctor similar to average, but very low % of population
who can get timely appointment with family doctor)
t Waits for CT scans, general surgery & cancer surgery
t Home care waits
t Avoidable hospitalizations (most indicators at provincial average; readmissions higher for asthma, GI bleed)
t Chronic disease management (diabetes complications, AMI survival)
t Use of right drugs for hospital patients with AMI, CHF
t C-section rates
t LTC safety and effectiveness (average for most indicators; higher (worse) rate of new starts of benzodiazepines
among residents)
t Home care safety and effectiveness (average results for most indicators; worse results for decline in cognitive
function and unintended weight loss)
t Average supply of family doctors and nurses; relatively low supply of specialists; relatively high supply of
registered practical nurses
t Preventive health screening (lower physical inactivity but higher smoking in pregnancy)
Worse than average results, major room
to improve
t Longer waits for a LTC bed
t Longer waits for hip and knee replacement
t Higher rate of avoidable ED visits by LTC residents, especially for low acuity visits
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
Overall
Worse by 23 days
Placement from hospital
Worse by 14 days
Placement from home
ALC (from 2008/09 to 2009/10)
126
Worse by 49 days
No major changes
11. LHIN Analyses
NORTHEAST LHIN
Superior results, no room to improve
t None
Better than average results, still
room to improve
t Shorter ED waits, especially for admitted patients
t Shorter wait for MRI, general surgery
Average results, still room to improve
t
t
t
t
t
t
Worse than average results, major
room to improve
t Longer waits for hip and knee replacement, urgent cancer surgery, cataract surgery
t More ALC hospital bed days
t Longer waits for a LTC bed, especially for people placed from hospital (but higher percentage of residents
placed in first choice of home)Higher percentage of residents placed into LTC who might not need to be there
(low MAPLe score)
t Access to primary care – lower proportion of population with a family doctor
t Home care waits
t Lower rate of use of right drugs for hospital patients with AMI
t More avoidable hospitalizations (high rates of admission for ambulatory care sensitive conditions, stroke and
AMI readmissions)
t Worse chronic disease management (higher rates of diabetes complications)
t Population health (higher rates of smoking, obesity, AMI incidence, injuries, intentional self-harm; however,
lower rates of physical inactivity)
Wait times for CT
C-section rates
LTC safety and effectiveness
Home care safety and effectiveness
Avoidable ED visits by LTC residents, rate of avoidable low acuity visits is worse than average
Preventive health screening
The Northeast has an average supply of family doctors, a relatively low supply of specialists and high supply of nurses and nurse practitioners.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
Overall
No major changes
Placement from hospital
Worse by 21 days
Placement from home
ALC (from 2008/09 to 2009/10)
No major changes
No major changes
127
11. LHIN Analyses
NORTHWEST LHIN
Superior results, no room to improve
t None
Better than average results, still
room to improve
t Shorter ED waits
t Shorter waits for CT, MRI and knee replacements
t Shorter time to home care visit after hospital discharge
Average results, still room to improve
t
t
t
t
t
t
Worse than average results, major
room to improve
t Lower access to primary care (higher % of population without a family doctor; more difficult to get appointment next day with family doctor)
t Longer waits for a LTC bed for people placed from the community
t Higher waits for urgent cancer surgery
t Lower use of right drugs for hospital patients with AMI, CHF
t Worse chronic disease management (higher rates of diabetes complications)
t More avoidable hospitalizations (high rates of hospitalization for ambulatory care sensitive conditions; highest
rate of readmissions for CHF; high stroke readmissions)
t LTC safety and effectiveness (higher rates of unintended weight loss; new starts of benzodiazepines; new
pressure ulcers; use of restraints)
t Population health (higher rates of smoking, smoking in pregnancy, obesity, binge drinking, AMI incidence,
injuries, intentional self-harm; however, lower rates of physical inactivity)
ALC hospital bed days
Waits for hip replacement, general surgery
C-section rates
Home care safety and effectiveness (most indicators at provincial average)
Avoidable ED visits by LTC residents
Preventive health screening (but rates of flu vaccination lower)
Note: The Northwest has an average supply of family doctors, relatively low supply of specialists and high supply of nurses and nurse practitioners.
CHANGES OVER TIME:
LTC waits (from Apr-Jun 09 to 2009/10)
ALC (from 2008/09 to 2009/10)
128
Overall
Worse by 21 days
Placement from hospital
Worse by 26 days
Placement from home
Better by 181 days
No major changes
MRI
Scans
CT Scans
= not significantly different from average
90th percentile wait time,
Dec 2010
Percentage of priority 4 cases
done within target, Dec 2010
Percentage of priority 3 cases
done within target, Dec 2010
Percentage of priority 2 cases
done within target, Dec 2010
90th percentile wait time, Dec
2010
Percentage of priority 4 cases
done within target, Dec 2010
Percentage of priority 3 cases
done within target, Dec 2010
Percentage of priority 2 cases
done within target, Dec 2010
Percentage of adults able to see their doctor
on the same day or next day the last time
they were sick or needed medical attention,
2009/10
Percentage of adults without a family doctor,
2009/10
90th percentile wait time for low complexity
ED patients, Sep 2010
90th percentile wait time for high complexity
ED patients, Sep 2010
Emergency Department - time from admission
to transfer to bed all levels, 2009/10
Emergency Department - time to MD
assessment by all levels, 2009/10
Emergency Department - Percentage of
patients left without being seen, 2009/10
= better than average
Accessible
2.3 Surgical Wait Times
and Access to
Specialists
Accessible
2.2 Access to
Primary Care
Accessible
2.1 Wait Times in
emergency
departments
Attribute/Theme Indicator
129
Directionality
113
30%
51%
75%
29
81%
64%
90%
43%
6.4%
4.3
11.7
3.0
1.2
4.7%
Ontario
= worse than average
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
Erie St. Clair
50
44%
78%
86%
28
88%
74%
96%
31%
6.2%
4.5
9.0
1.8
1.2
5.2%
South West
70
38%
51%
72%
25
87%
78%
90%
46%
6.1%
3.8
9.3
1.8
0.9
3.4%
Waterloo
Wellington
61
62%
27%
78%
26
95%
56%
81%
48%
4.3%
5.3
10.1
2.1
1.5
6.1%
Hamilton Niagara
Haldimand Brant
120
15%
40%
57%
41
70%
56%
90%
45%
3.0%
4.7
14.9
4.0
1.1
5.7%
Central West
128
19%
57%
70%
14
100%
75%
97%
49%
7.3%
4.1
11.7
3.3
1.6
5.8%
Mississauga
Halton
141
13%
74%
90%
23
89%
60%
88%
49%
5.0%
3.7
10.1
3.8
1.3
4.5%
Toronto Central
125
39%
51%
76%
35
74%
70%
95%
48%
8.0%
4.9
14.2
3.5
1.5
5.3%
Central
124
30%
53%
66%
41
78%
59%
96%
44%
6.0%
3.8
13.2
6.0
1.5
5.3%
Central East
104
32%
38%
65%
27
85%
57%
81%
40%
5.8%
4.3
11.8
4.5
1.4
5.3%
South East
100
22%
20%
61%
16
93%
76%
78%
46%
2.4%
4.1
9.4
2.3
0.9
3.6%
Champlain
104
35%
60%
84%
34
68%
61%
93%
42%
10%
5.2
13.2
2.9
1.3
4.6%
North Simcoe Muskoka
94
17%
43%
94%
32
81%
70%
96%
23%
5.9%
3.7
8.8
3.5
1.0
4.1%
North East
113
41%
56%
73%
30
81%
53%
88%
34%
14%
4.1
10.6
1.9
0.9
3.9%
76
23%
71%
93%
23
87%
81%
96%
27%
12%
4.2
11.2
1.8
0.8
3.4%
North West
= better than average
90th percentile wait time, Dec
2010
Percentage of priority 4 cases
done within target, Dec 2010
Percentage of priority 3 cases
done within target, Dec 2010
Percentage of priority 2 cases
done within target, Dec 2010
90th percentile wait time, Dec
2010
Percentage of priority 4 cases
done within target, Dec 2010
Percentage of priority 3 cases
done within target, Dec 2010
Percentage of priority 2 cases
done within target, Dec 2010
90th percentile wait time, Dec
2010
Percentage of priority 4 cases
done within target, Dec 2010
Percentage of priority 3 cases
done within target, Dec 2010
Percentage of priority 2 cases
done within target, Dec 2010
90th percentile wait time, Dec
2010
Percentage of priority 4 cases
done within target, Dec 2010
Percentage of priority 3 cases
done within target, Dec 2010
Percentage of priority 2 cases
done within target, Dec 2010
= not significantly different from average
Knee
Replacements
Hip
Replacements
Cataract
Surgeries
Cancer
Surgeries
* NV= no value for this LHIN
Accessible
2.3 Surgical Wait Times
and Access to
Specialists
Attribute/Theme Indicator
130
Directionality
200
88%
63%
63%
206
84%
66%
74%
122
98%
83%
90%
51
93%
78%
67%
Ontario
81%
97%
43
96%
86%
87%
Erie St. Clair
126
94%
89%
NV
93
100%
100%
NV
68
100%
= worse than average
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
South West
211
86%
44%
NV
163
95%
54%
83%
72
99%
99%
29%
71
84%
67%
54%
Waterloo
Wellington
176
90%
69%
NV
97
100%
80%
NV
94
100%
100%
NV
40
96%
91%
64%
Hamilton Niagara
Haldimand Brant
209
86%
49%
57%
235
74%
62%
73%
143
98%
72%
75%
56
89%
72%
73%
Central West
180
90%
86%
NV
131
100%
NV
NV
116
99%
NV
NV
62
93%
82%
NV
Mississauga
Halton
138
94%
75%
NV
128
91%
63%
NV
160
96%
89%
NV
54
96%
85%
71%
Toronto Central
135
96%
85%
100%
125
91%
95%
91%
112
100%
96%
NV
55
88%
72%
60%
Central
166
94%
82%
NV
140
100%
88%
NV
82
100%
100%
100%
34
99%
92%
81%
Central East
172
90%
78%
63%
185
81%
74%
NV
156
96%
81%
NV
43
99%
85%
56%
South East
160
79%
74%
NV
141
94%
75%
50%
93
99%
98%
NV
40
88%
83%
NV
Champlain
226
81%
34%
NV
351
51%
26%
63%
169
94%
55%
NV
49
98%
79%
71%
North Simcoe Muskoka
228
80%
45%
NV
243
67%
47%
NV
151
97%
97%
60%
44
100%
80%
67%
North East
427
63%
61%
NV
323
82%
53%
NV
124
93%
59%
NV
47
89%
67%
50%
173
92%
77%
NV
203
86%
NV
NV
78
98%
NV
NV
32
100%
91%
56%
North West
Percentage of
seniors hospitalized for CHF who,
within 90 days
post-discharge,
filled a prescription
for: (2009/10)
Percentage of
seniors hospitalized for AMI who,
within 90 days
post-discharge,
filled a prescription
for: (2009/10)
= better than average
* NV= no value for this LHIN
Effective
3.1 Use of right
treatments in
hospital
Median number of
days to long-term
care home placement, 2009/10:
Accessible
2.4 Access to longterm care and
home care
BETTER
Percentage of priority 4
cases done within target,
Dec 2010
from community
from acute care hospital
overall
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
= not significantly different from average
both beta-blocker and
ACEI/ARB
ACEI/ARB
beta-blocker
all three drugs
statin
ACEI/ARB
beta-blocker
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
Percentage of priority 3
cases done within target,
Dec 2010
90th percentile wait time,
Dec 2010
BETTER
Directionality
Percentage of priority 2
cases done within target,
Dec 2010
Percentage of residents who are placed in their
first choice of LTC home, 2009/10
General Surgeries
Accessible
2.3 Surgical wait times
and access to
specialists
Attribute/Theme Indicator
131
Ontario
45%
68%
61%
57%
86%
76%
77%
39%
119
44
92
101
94%
87%
89%
Erie St. Clair
= worse than average
50%
71%
66%
59%
87%
78%
79%
39%
173
58
113
97
97%
91%
83%
South West
48%
70%
63%
57%
82%
78%
79%
40%
125
47
84
104
97%
92%
82%
Waterloo
Wellington
59%
78%
73%
68%
87%
83%
87%
34%
266
64
182
79
96%
98%
NV
Hamilton Niagara
Haldimand Brant
50%
75%
65%
57%
86%
79%
76%
43%
215
107
178
104
96%
87%
72%
Central West
51%
71%
71%
66%
93%
83%
80%
30%
77
28
47
60
99%
100%
100%
Mississauga
Halton
50%
73%
64%
61%
88%
82%
76%
36%
176
40
120
86
99%
88%
91%
Toronto Central
51%
69%
68%
62%
88%
77%
80%
43%
195
63
98
110
96%
83%
78%
Central
51%
72%
67%
61%
90%
79%
81%
36%
194
48
116
80
99%
98%
100%
Central East
49%
70%
67%
60%
89%
79%
79%
36%
144
83
114
85
99%
94%
83%
South East
52%
66%
72%
63%
89%
81%
83%
40%
148
61
111
99
96%
89%
63%
Champlain
52%
69%
70%
63%
90%
78%
83%
39%
314
58
209
154
93%
89%
88%
North Simcoe Muskoka
49%
71%
65%
58%
86%
77%
80%
36%
223
85
143
101
100%
83%
95%
North East
48%
70%
62%
46%
82%
72%
72%
49%
151
125
133
90
98%
94%
79%
46%
73%
59%
51%
87%
75%
72%
35%
229
71
139
107
93%
91%
81%
North West
Effective
3.3 Potentially
avoidable
hospitalizations
Effective
3.2 Chronic disease
management
Effective
3.1 Use of right
treatments
in hospital
Rate of readmission
to acute care hospital within 30 days of
being discharged for:
(2009/10)
132
diabetes
gastrointestinal
GI bleed
stroke (medical)
COPD
asthma
CHF
AMI
Rates of hospitalizations for ambulatory care
sensitive conditions in Ontario, 2009/10
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
Adjusted mortality rate in the year after diagnosis of congestive heart failure (CHF), 2008/09
Adjusted rate of death per 100 heart attack
patients between 30 days and one year after
their first heart attack, 2008/09
BETTER
BETTER
BETTER
Rate of people with diabetes who had any
serious diabetes complication, 2009/10
both statin and
ACEI/ARB
an ACEI/ARB
BETTER
BETTER
Percentage diabetes patients who had an eye
exam in the past 12 months, 2009/10
a statin
BETTER
Rate of low-risk first-time mothers who deliver a
full-term baby via Caesarean section per
100 deliveries, 2009/10
Percentage of elderly
diabetes patients
regularly taking:
BETTER
Directionality
Rate of delivering via Caesarean section per
100 deliveries, 2009/10
Attribute/Theme Indicator
132
Ontario
5.38
7.8
1.75
2.64
7.65
3.86
11.09
4.25
278
9.1
35
4.3
48%
67%
60%
51%
15%
28%
Erie St. Clair
3.9
8.3
2.8
2.9
7.2
5.1
13
5.1
338
9.7
37
4.7
46%
69%
58%
54%
13%
25%
South West
4.7
8.2
2.1
3.1
6.4
4.1
8.5
3.9
300
10
40
4.5
45%
67%
58%
54%
10%
22%
Waterloo
Wellington
2.0
7.5
2.5
1.9
8.0
1.3
7.9
3.6
236
9.8
35
4.4
46%
68%
58%
55%
13%
26%
Hamilton Niagara
Haldimand Brant
7.9
7.7
1.8
2.5
8.1
3.5
11
4.2
325
9.6
35
4.7
50%
71%
61%
53%
15%
29%
Central West
2.2
6.7
1.2
2.4
7.4
5.9
11
6.3
280
8.8
30
3.8
47%
66%
59%
46%
19%
30%
Mississauga
Halton
1.7
6.7
1.1
2.1
5.8
4.7
10
3.0
203
8.9
33
3.4
48%
66%
60%
49%
13%
28%
Toronto Central
7.6
8.1
1.4
3.5
12
3.4
12
3.2
241
10
36
4.2
47%
64%
60%
46%
17%
30%
Central
4.5
7.1
1.1
2.9
5.0
4.0
11
3.7
181
9.3
36
3.4
47%
65%
60%
47%
15%
30%
Central East
8.3
8.0
2.6
1.9
7.7
3.9
10
3.3
254
9.1
35
4.1
51%
70%
63%
51%
16%
30%
South East
7.6
8.1
1.6
1.2
10
0.0
11
3.5
317
9.7
38
4.8
47%
67%
60%
55%
16%
28%
Champlain
6.1
7.1
0.8
1.9
8.1
2.3
12
3.1
257
8.8
36
4.3
46%
65%
60%
52%
13%
29%
North Simcoe Muskoka
5.8
9.0
2.5
2.1
6.7
6.1
12
3.3
317
9.9
41
4.9
48%
69%
60%
51%
17%
31%
North East
5.9
9.2
1.4
4.1
7.0
2.9
12
8.2
491
10
37
5.4
46%
70%
59%
55%
14%
29%
4.3
8.2
3.1
2.5
6.7
0.0
16
5.1
529
9.5
35
5.7
46%
69%
57%
55%
14%
25%
North West
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
BETTER
recent decrease in language,
memory and thinking abilities
recent unintended
weight loss
bladder function has
recently decreased or
did not improve
a new problem with normal
everyday tasks (getting
dressed, eating, personal
hygiene) OR an old problem
that is not getting better
pain that is not well
controlled
serious signs of depression
(e.g. profound sadness,
withdrawal from normal
activities)
recent decline in language,
memory and thinking abilities
new problem communicating
or understanding others or
an existing problem that did
not improve over a period
of time
recent unintended weight
loss
4.3%
17%
51%
9%
24%
46%
50%
7.1%
13%
26%
12%
33%
21%
Ontario
Erie St. Clair
3.3%
14%
43%
6.1%
24%
45%
47%
7.3%
15%
32%
14%
38%
25%
= worse than average
BETTER
BETTER
BETTER
BETTER
Directionality
worsening symptoms of
depression or anxiety
pain that got worse recently
increasing difficulty carrying
out normal, everyday tasks
(getting dressed, eating,
personal hygiene)
worsening bladder control
= not significantly different from average
Percentage of
long-stay home
care clients in
2009/10 with:
Effective
3.5 Keeping people
healthy in home
care
= better than average
Percentage of
LTC residents
in 2009/10
with:
Effective
3.4 Keeping people
healthy in longterm care
Attribute/Theme Indicator
133
South West
4.2%
17%
47%
8.2%
22%
41%
48%
6.8%
15%
30%
14%
36%
25%
Waterloo
Wellington
5.3%
18%
52%
7.6%
23%
55%
54%
8.9%
14%
32%
13%
35%
23%
Hamilton Niagara
Haldimand Brant
5.2%
18%
52%
8.2%
24%
48%
52%
6.3%
14%
30%
14%
38%
24%
Central West
5.9%
21%
61%
11%
22%
60%
59%
7.8%
12%
21%
10%
31%
19%
Mississauga
Halton
3.8%
17%
47%
7.2%
23%
51%
54%
6.3%
14%
24%
10%
31%
18%
Toronto Central
4.8%
19%
57%
12%
25%
52%
47%
6.7%
10%
17%
9%
30%
17%
Central
2.8%
16%
49%
14%
24%
45%
55%
7.1%
11%
18%
9%
28%
17%
Central East
4.3%
18%
55%
9.8%
24%
46%
49%
6.9%
12%
24%
10%
31%
19%
South East
4.3%
20%
54%
6.4%
25%
49%
49%
7.2%
11%
30%
13%
36%
20%
Champlain
3.9%
20%
62%
8.1%
24%
43%
50%
6.5%
14%
27%
12%
34%
21%
North Simcoe Muskoka
6.0%
19%
57%
8.3%
23%
43%
53%
8.0%
14%
29%
13%
34%
22%
North East
4.6%
15%
46%
7.0%
20%
41%
44%
6.8%
12%
26%
14%
34%
23%
5.1%
17%
50%
7.9%
24%
45%
50%
12%
9.4%
25%
11%
30%
24%
North West
BETTER
BETTER
BETTER
Percentage of people placed into an LTC home
who do not have with high or very high needs
for LTC services (or care needs) as measured
using the MAPLe scores, 2009/10
Number of non-urgent, avoidable ED visits per
100 LTC residents per year, 2009/10
Rates (per 100 person years) of Low Acuity ED
Visits by LTC Residents, 2009/10
Efficient
6.3 Avoidable
emergency
department visits
BETTER
Percentage of acute care bed days which
are designated as alternative level care (ALC)
2009/10
BETTER
unexplained injuries, burns,
or fracture
Efficient
6.2 Right service
in right place
BETTER
a new pressure ulcer (stage
2 or higher)
Percentage of
long-stay home
care clients in
2009/10 with:
BETTER
BETTER
BETTER
BETTER
Safe
4.5 Avoiding harm
in community
a fall in the last 90 days
a fall in the last 30 days
physical restraint
a recent bladder infection
BETTER
behaviour that has worsened
recently
BETTER
Rate of falls among seniors (aged 65+) resulting
in an emergency department visit or inpatient
hospitalization per 100 resident-years in longterm care homes, 2008/09
BETTER
BETTER
Incidence of new starts of benzodiazepines
in seniors newly admitted to long-term care
homes, 2008/09
a new pressure ulcer (stage
2 or higher)
BETTER
Incidence of new starts of antipsychotics without a clear indication in seniors newly admitted
to long-term care homes, 2008/09
Percentage of
LTC residents
in 2009/10
with:
BETTER
Percentage of elderly long-term care residents
prescribed a drug that should be avoided in the
elderly (Beers list), 2009/10
Safe
4.4 Drug Safety in
long term care
Safe
4.3 Avoiding harm
in long term
care homes
BETTER
Adjusted death rate from heart attack per 100
patients within 30 days, 2008/09
Directionality
Safe
4.3 Mortality in hospital
Attribute/Theme Indicator
134
Ontario
7.8
21.2
23%
16%
12%
1.5%
25%
14%
17%
5.4%
14%
2.7%
14.0
24%
14%
19%
9.6
Erie St. Clair
7.9
22
24%
11%
10%
1.7%
27%
14%
22%
5.2%
16%
3.4%
13
21%
17%
21%
10
South West
9.8
20
24%
12%
12%
1.4%
24%
15%
17%
5.8%
15%
3.1%
13
25%
14%
20%
10
Waterloo
Wellington
7.4
14
20%
18%
10%
2.0%
27%
15%
19%
5.4%
16%
3.1%
12
24%
10%
17%
9.3
Hamilton Niagara
Haldimand Brant
5.9
17
22%
21%
13%
2.1%
29%
14%
17%
6.2%
15%
3.0%
13
28%
17%
18%
11
Central West
4.4
26
23%
10%
11%
1.7%
26%
14%
9%
5.1%
11%
2.7%
15
32%
21%
18%
10
Mississauga
Halton
3.4
25
22%
9%
12%
1.7%
28%
14%
11%
5.8%
13%
2.5%
15
22%
9%
16%
11
Toronto Central
6.1
24
23%
12%
13%
1.5%
23%
14%
10%
4.4%
10%
2.8%
13
20%
10%
16%
10
Central
6.2
25
23%
15%
12%
1.5%
23%
13%
12%
4.5%
10%
2.2%
15
25%
15%
18%
9.8
Central East
9.1
23
24%
18%
12%
1.2%
23%
13%
18%
4.3%
12%
2.5%
15
29%
12%
19%
11.5
South East
9.2
17
23%
17%
12%
1.6%
26%
14%
24%
6.9%
15%
3.0%
12
22%
20%
22%
8.9
Champlain
9.4
21
20%
16%
10%
1.4%
25%
14%
23%
5.8%
15%
2.7%
16
14%
11%
17%
8.7
North Simcoe Muskoka
11.4
23
23%
20%
9%
3.6%
30%
14%
14%
6.4%
15%
2.9%
16
31%
17%
22%
13
North East
11.3
20
31%
28%
13%
1.2%
25%
15%
20%
5.4%
14%
2.4%
16
24%
10%
22%
14
8.1
25
20%
18%
7%
1.6%
28%
14%
23%
5.0%
11%
3.7%
15
31%
13%
20%
8.2
North West
= not significantly different from average
12%
88%
56%
49%
18%
21%
18%
19%
29%
231
713
11
99
88
17%
3.93
Ontario
= worse than average
BETTER
Percentage of women who smoked during their
pregnancy, 2009/10
BETTER
BETTER
BETTER
BETTER
have inadequate fruit and
vegetable intake
are physically inactive
are obese
have had binge drinking
episodes
Percentage of mothers breastfeeding right after
birth, 2009
= better than average
Focused on
Population Helath
9.2 Maternal and
child health
Percentage of non-smokers in the general
population aged 12+ years who report being
regularly exposed to tobacco smoke in any of
their home, vehicle or in public places, 2009
BETTER
BETTER
Percentage of the general population age 12
and above who report smoking, 2009
Focused on
Population Helath
9.1 Unhealthy behaviour
Percentage of
the population
age 12 and
above who:
(2009)
BETTER
Percentage of stroke patients discharged from
acute care to inpatient rehabilitation, 2010
registered practical
nurses, 2010
registered nurses, 2010
nurse practitioners, 2010
specialists, 2009
Integrated
8.1 Discharge/
transitions
BETTER
BETTER
BETTER
Supply, per
100,000
people, of:
family physicians, 2009
Percentage of elderly patients with uncomplicated hypertension treated with diuretic as first-line
treatment, 2009/10
Rate of pre-operative chest X-ray testing per
100 cataract surgeries, 2009/10
Directionality
Appropriately resourced
7.4 Health human
resources
Efficient
6.4 Avoiding unnecessary drugs and tests
Attribute/Theme Indicator
135
Erie St. Clair
18%
68%
62%
51%
21%
22%
18%
21%
34%
260
680
12
61
64
13%
3.1
South West
18%
86%
61%
51%
22%
21%
19%
22%
28%
305
929
15
110
84
20%
3.1
Waterloo
Wellington
13%
92%
58%
50%
17%
23%
16%
18%
25%
233
554
12
60
80
20%
2.6
Hamilton Niagara
Haldimand Brant
17%
80%
59%
45%
20%
23%
18%
21%
25%
262
736
12
102
78
16%
3.5
Central West
6%
90%
48%
60%
17%
14%
16%
14%
22%
98
308
3
47
65
19%
3.7
Mississauga
Halton
6%
93%
51%
49%
14%
22%
19%
17%
33%
110
474
4
62
75
15%
3.9
Toronto Central
5%
95%
58%
51%
13%
22%
11%
13%
28%
238
1374
23
298
141
15%
5.3
Central
4%
92%
58%
52%
14%
16%
18%
17%
29%
140
437
3
70
81
13%
5.7
Central East
11%
88%
55%
55%
19%
17%
24%
18%
34%
195
501
6
60
70
14%
4.5
South East
24%
80%
54%
41%
22%
23%
20%
24%
25%
374
901
17
112
104
21%
3.4
Champlain
11%
94%
53%
42%
19%
26%
15%
18%
29%
269
859
13
132
114
22%
3.5
North Simcoe Muskoka
19%
82%
56%
42%
18%
25%
21%
27%
27%
294
682
12
55
88
17%
3.3
North East
27%
86%
59%
44%
26%
24%
20%
26%
25%
411
927
25
66
95
19%
3.4
36%
82%
58%
39%
27%
28%
17%
25%
36%
465
1065
31
71
108
22%
7.4
North West
BETTER
BETTER
BETTER
Percentage of people (aged 50-74) who
reported having a fecal occult blood test in the
2 years prior to the survey, 2009
Rate of women aged 65 years who have had a
bone mineral density (BMD) test since turning
55 years of age, 2009/10
Mortality age-standardized rates per 100,000
for colon and rectum, 2003-2007
= better than average
BETTER
Rate of injury-related hospitalizations
per 100,000, 2009/10
404
8,845
88
203
20
81%
35%
72%
67%
72%
8.6
Ontario
= worse than average
BETTER
Rate of injury-related ED visits per 100,000,
2009/10
= not significantly different from average
BETTER
Rate of ED visits for intentional self-harm
per 100,000, 2009/10
BETTER
BETTER
Percentage of women (aged 20-69) who
reported having a Pap test in the last three
years,2007/09
AMI incidence per 100,000, 2009/10
BETTER
Percentage of women (aged 50-69) who
reported having a mammogram in the last
two years,2008/09
Focused on
Population Helath
9.5 Deaths and
harm that could
be avoided by
prevention
BETTER
Percent of the population aged 65+ reporting
having received a flu shot in the past year, 2009
Focused on
Population Helath
9.4 Preventive
measures
BETTER
HIV incidence per 100,000, 2008
Directionality
Focused on
Population Helath
9.3 Sexual health
Attribute/Theme Indicator
136
Erie St. Clair
444
9126
77
237
21
71%
40%
68%
69%
77%
2.9
South West
548
12964
107
212
22
73%
35%
72%
67%
74%
3.6
Waterloo
Wellington
413
8088
120
219
19
82%
40%
74%
66%
73%
4.1
Hamilton Niagara
Haldimand Brant
489
10097
107
251
20
85%
33%
72%
65%
73%
6.8
Central West
303
6446
57
202
15
83%
30%
69%
62%
69%
2.3
Mississauga
Halton
315
6665
61
164
19
87%
42%
72%
67%
63%
5.2
Toronto Central
352
6927
69
150
19
86%
25%
70%
60%
71%
43
Central
290
6571
49
149
18
88%
35%
74%
70%
71%
4.5
Central East
360
8486
90
198
19
84%
33%
72%
68%
76%
3.5
South East
387
12815
135
216
21
74%
36%
77%
66%
78%
3.5
Champlain
343
8276
84
194
22
83%
41%
79%
70%
72%
14
North Simcoe Muskoka
491
11530
110
242
22
84%
32%
70%
63%
68%
1.8
North East
679
13579
156
282
21
71%
34%
71%
67%
73%
6.5
822
14913
224
299
21
57%
40%
72%
69%
66%
2.1
North West
11. LHIN Analyses
137
12. Examples of Success
12.1
Examples of success — Reducing ED waits
Aims and Measures: increase the percentage of admitted and non-admitted
patients treated within the recommended timeframe (four and eight hours
respectively) and decrease the 90th percentile amount of time spent in the
ED, for admitted patients, high-acuity non-admitted patients and low-acuity
non-admitted patients.
Change Ideas:
Mount Sinai Hospital:
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an internal waiting room is used to assess patients who don’t require
care in a stretcher on an ongoing basis, but do require privacy for
their examination or treatment. This waiting room allows patients to
effectively “share” a stretcher, which speeds up processing and reduces
wait times.
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care for patients who arrive by ambulance.
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hours for CT scans, add technologists on some night shifts and work
closely with Diagnostic Imaging to reduce wait times for ED patients.
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by adjusting roles and enhancing nursing and clerical hours.
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the floor by inpatient units rather than being “pushed” out of the ED.
Inpatient units were given increased decision-making authority to
augment staff based on increases in activity.
Positive engagement of front line physicians, nurses and inpatient medicine
units was an important success factor for all sites.
Results:
These three hospitals have achieved major reductions in ED waits, over a
time period of just under three years. For low acuity patients, Mount Sinai
decreased the 90th percentile time spent in the ED by 2 hours, and
Oakville-Trafalgar and Georgetown decreased this time by one hour. For
high acuity patients, Mount Sinai dropped the time spent in the ED by
7.1 hours, a decrease of more than a third. Oakville-Trafalgar and
Georgetown decreased this time by 2.1 and 1.4 hours respectively.
Mount Sinai Hospital
20
90th percentile time (hours)
spent in ED
Organizations: Mount Sinai Hospital, a major Toronto teaching hospital;
Oakville-Trafalgar Memorial Hospital, a very high volume community hospital;
and Georgetown Hospital, a high volume community hospital. The two
community hospitals are a part of Halton Healthcare Services.
0
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policy and process changes that have improved flow of admitted
patients from the ED to in-patient units.
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liaison between the ED and in-patient units.
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on one area of ED care; for example, having a Medical Lab Assistant
initiate laboratory tests, manage flow or process orders — tasks
previously completed by overburdened nurses.
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progress and barriers.
Georgetown Hospital:
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similar acuity level, and establish a Rapid Assessment and Fast Track
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High
Low
target 8 hours
(high acuity)
target 4 hours
(low acuity)
10
0
Apr-Jun 08
Oct-Dec 10
Georgetown
20
High
Low
target 8 hours
(high acuity)
10
0
138
Oct-Dec 10
20
90th percentile time (hours)
spent in ED
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target 4 hours
(low acuity)
Apr-Jun 08
Oakville-Trafalgar
90th percentile time (hours)
spent in ED
Oakville-Trafalgar Memorial Hospital:
High acuity
Low acuity
target 8 hours
(high acuity)
10
target 4 hours
(low acuity)
Apr-Jun 08
Oct-Dec 10
12. Examples of Success
Leading Results in Ontario, October-December 2010:
Other hospitals in Ontario can aim to meet or exceed the results achieved
by these organizations:
Hospital
Type
90th percentile
length of stay
Percentage of patients treated within
recommended time frame
Low acuity
High acuity
Admitted patients
Non-admitted high
acuity patients
Non-admitted low
acuity patients
Mount Sinai
Teaching hospital
5.1 hrs
13.2 hrs
32%
91%
85%
Oakville-Trafalgar
Very high volume
community hospital
3.7 hrs
6.9 hrs
72%
100%
95%
Georgetown
High volume
community hospital
3.7 hrs
5.1 hrs
93%
100%
95%
139
12. Examples of Success
12.2
Examples of success — Primary care
Organizations:
Ideas to improve the efficiency include:
– The North York Family Health Team (FHT), a large interdisciplinary team
which includes 56 physicians, nurses, nurse practitioners, pharmacists,
social workers and dieticians. The FHT serves 54,000 patients across
nine locations in North York.
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and equipment so providers have easy access to the tools they need.
– The Smithville Medical Centre Family FHT, which includes 8 family
physicians and nursing staff, and serves the small community of
Smithville, just southeast of Hamilton.
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documentation and file retrieval times.
Results:
Teams with improved average time to third next available appointment
Aims and measures:
t .
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departure (“office cycle time”) to under 60 minutes.
t &
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TQFOUXJUIBQSPWJEFSUIFi3FE;POF5JNFwUBSHFU
t *NQSPWFQIZTJDJBODPOUJOVJUZTPQBUJFOUTTFFUIFJSPXOQSPWJEFSBUMFBTU
85% of the time.
Change Ideas:
Ideas related to scheduling include:
t .
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continuously to ensure they are in balance.
t 5
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the backlog.
t *ODSFBTJOHUIFJOUFSWBMCFUXFFOWJTJUTGPSTUBCMFQBUJFOUTXJUIDISPOJD
disease from four times a year to twice a year to make more room for
other patients.
t 4
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appointments for patients who call in the morning.
140
25.0
Average time to third next
available appointment
t 3
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next available appointment.
North York
FHT
12.5
0.0
Smithville
Medical
Centre
FHT
Apr 09
Oct 10
The following represents results for selected physician practices within
each FHT:
t #
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appointment; at Smithville Medical Centre FHT, this wait time dropped
to zero days in August 2009.
t #
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average office cycle time of under 60 minutes.
t #
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North York FHT has achieved almost 100% since April 2010.
Each FHT is currently in the process of spreading these improvements to all
physicians and patients within the practice.
12. Examples of Success
12.3
Examples of success — Surgical wait times
Organization: North York General Hospital
Aims and measures: Maximize the percentage of patients who receive
their surgery within the recommended wait time, for hip and knee replacement, cataract, general and cancer surgery.
t 6
TFXBJUUJNFTGVOEJOHUPIFMQGVOEBEFEJDBUFEXBJUUJNFTTUSBUFHZ
co-ordinator to develop and track action plans to support programs to
meet identified targets and monitor the booking schedule.
t %
FWFMPQBOPOMJOFCPPLJOHTZTUFNUPSFEVDFFSSPSTBOEEFMBZTEVFUP
lost paperwork, illegible writing or incomplete information.
t %
FQMPZBDPNQSFIFOTJWFCFENBOBHFNFOUTZTUFNUIBUJTVQEBUFE
every four hours, to track which beds are available at any moment and
establish standard protocols to put the right patient into the right bed.
This helps prevent situations where a surgical case is cancelled at the
last minute because no beds are available.
t 1
SPWJEFUSBJOJOHUPTVSHFPOTBENJOJTUSBUJWFBTTJTUBOUTPOIPXUP
complete bookings. This includes on-site visits, phone training, and
FAQs (frequently asked questions) and is repeated when there is
turnover of these assistants.
t &
OTVSFUIFSFJTUIFSJHIUDBQBDJUZUPNFFUEFNBOE8BJU5JNFT
Funding has been used to increase operating room time and new
surgeons and other health professionals have been added to meet
increases in demand.
t 3
FWJFXTVCNJUUFEDBTFTEBJMZUPWBMJEBUFJGDBTFTIBWFCFFOFOUFSFE
correctly. If there is a problem, the surgeon’s office is notified
immediately.
t )
BWFB4VSHJDBM1SPHSBN%JSFDUPSQSFTFOURVBSUFSMZSFWJFXTUP
all members of the Surgical Program to celebrate successes,
initiate discussions to review barriers and implement action plans
to improve results.
t $
POUJOVPVTMZGPMMPXVQXJUITVSHFPOTPGmDFTUPJEFOUJGZBOEBEESFTT
quality issues, such as entering bookings on time, assigning correct
priority levels, entering patients’ unavailable dates, etc.
Results:
Change Ideas:
t ' PSDBODFSTVSHFSZIBWFNVMUJEJTDJQMJOBSZDBODFSDPOGFSFODFTUPBMMPX
case review, improve care and ensure the right care is provided at the
right time.
Surgery Type
North York General now ensures that 100% of patients in all priority
categories and all types of surgery are served within the recommended
timeframe.
Percentage of patients in all priority categories
served within recommended timeframe
July-September 2009
July-September 2010
General Surgery
100%
100%
Cancer Surgery
100%
100%
Cataract surgery
100%
100%
Hip replacement
100%
100%
Knee replacement
100%
100%
141
12. Examples of Success
12.4
Examples of success — MRI wait times
Aims and measures: Reduce the 90th percentile wait time for MRI scans.
Change Ideas:
Windsor Regional Hospital applied Lean methods to MRI scans. They
conducted value stream maps, identifying each step in the process, waits
between steps and error rates at each step. They found major inefficiencies, including incomplete requisitions sent in by ordering physicians.
Radiologists need accurate information about the patient’s clinical condition
in order to select the right protocol (e.g. the areas to be scanned and
whether contrast dyes, drugs or procedures need to be administered). If
this information is missing, then the test is delayed. Staff made multiple
phone calls to correct information and sometimes re-booked patients
multiple times. Also, when patients were left not knowing their appointment
time due to the above delays, they would call the office for information,
which in turn wasted more staff time. Ideas for improvement include:
t 3
FWJTJOHUIFSFRVJTJUJPOGPSNGPSPSEFSJOHBO.3*UPDMBSJGZUIF
exact information that ordering physicians needed to communicate
to the radiologist.
t 5
SBDLJOHXIJDIPSEFSJOHQIZTJDJBOTSFQFBUFEMZTFOUJOJODPNQMFUF
requisitions and having them re-submit — which puts the onus on
them to get it right the first time.
t 6
TJOHBOFMFDUSPOJDTDIFEVMFSTZTUFNUPNBLFJUFBTJFSUPUSBDL
appointment times.
t *OGPSNJOHQBUJFOUTPGUIFUJNFQFSJPEXJUIJOXIJDIUIFZDPVMEFYQFDU
to receive an appointment time, which reduced unnecessary
phone inquiries.
St. Joseph’s Health Care, London participated in the provincial MRI process
improvement project, and also applied LEAN techniques. It found that it
took too long to book the test after receiving a requisition; that the time
booked for a scan often didn’t match the actual time required, leading to
idle scanner time; and wasted staff time due to unnecessary interruptions
or looking for supplies. Ideas for improvement include:
– Streamlining the booking and protocol-setting process, which decreased
booking time from 13 to 1.5 days.
– Improved scheduling, which better matched the expected time to do a
scan with the actual time.
– Better organization of supplies to reduce wasted time searching for them.
St. Joseph’s also added a second scanner, which added about 10% extra
capacity. (Before, one scanner was used around the clock and weekends;
afterwards, two scanners were used 16 hours per weekday).
Results:
Windsor regional hospital has cut its 90th percentile MRI wait times by more
than half, and St. Joseph’s Health Care has dramatically reduced its waits to
less than a third of what they used to be in early 2008.
Windsor regional Hospital
200
90th percentile wait time
for MRI (days)
Organizations: Windsor Regional Hospital (a very large community hospital
with two campuses), and St. Joseph’s Health Care, London.
100
58
26
Hospital
Target
0
t &OTVSJOHUIBUUIFSFXBTDPOTJTUFOUDPEJOHPGQSJPSJUZMFWFMTGPSTDBOT
Jan–Mar 08
Oct–Dec 10
t #PPLJOHTDBOTPOBmSTUJOmSTUPVUCBTJT
t 4
UBOEBSEJ[JOHQSPUPDPMT5IJTSFEVDFEUIFUJNFSBEJPMPHJTUTTQFOUPO
designing the protocols, decreased the use of contrast dye (which is
costly and adds extra time), and shortened the average time per patient
by decreasing the number of unnecessary scans that were sometimes
included in protocols.
t #
PPLJOHTJNJMBSCPEZQBSUTPOTBNFEBZUPSFEVDFTFUVQUJNFUP
change coils on the machine for doing a different body part.
t #
PPLJOHNPSFDPNQMFYDBTFTEVSJOHUIFEBZXJUIMBUFSIPVSTVTFEGPS
priority 4 cases when additional resources are not required.
142
St Joseph’s Health Care, London
200
90th percentile wait time
for MRI (days)
Windsor also uncovered wasted time in planning and performing scans.
Ideas included the following:
177
100
55
0
Jan–Mar 08
Oct–Dec 10
Hospital
Target
12. Examples of Success
12.5
Examples of success — Chronic disease management
Organizations: Petawawa Centennial Family Health Team (FHT), which
serves 15,000 people, and Timmins FHT, which has 24 family physicians
and five nurse practitioners.
Aims and measures: Improve management of type 2 diabetes, including
improving screening to prevent vascular complications, ensuring appropriate treatment and encouraging self-management. Specific targets are noted
in the results table below.
Change Ideas:
Both of these sites implemented a variety of changes related to the
redesign of how care is delivered, including:
t BOFMFDUSPOJDNFEJDBMSFDPSE&.3
t VTFPGHSPVQNFEJDBMWJTJUTEFWFMPQFEGSPN*NQBDU#$TNPEFM
where participants with diabetes learn in a group about lifestyle
improvements, healthy living, interpretation of lab tests and how
to set personal goals; and,
t QSPNPUJPOPGDISPOJDEJTFBTFTFMGNBOBHFNFOU"U5JNNJOTUIF
Registered Nurse Program Lead was responsible for championing
this approach and documenting patient self-management goals.
Timmins also worked to ensure diabetes patients are booked close to their
birthday for an annual physical, during which a comprehensive care plan is
developed. Petawawa also reorganized work flow so that lab work would
routinely be done ahead of scheduled appointments, not afterwards.
Results:
t BEJBCFUFTQBUJFOUSFHJTUSZ
t B
OFMFDUSPOJDEJBCFUFTnPXTIFFUUPSFNJOEQSPWJEFSTUPGPMMPXBOE
document the use of evidence-based practices at each visit;
The following represents results for pilot sites within each FHT. Each FHT is
currently in the process of spreading these improvements to all physicians
and patients within the practice.
t B
QBUJFOUGPMMPXVQTZTUFNUPFOTVSFUIBUQBUJFOUTBSFSPVUJOFMZ
notified of when follow-up appointments need to take place so that no
one misses them;
Petawawa Centennial FHT
Baseline (May
2009)
Most recent
value (October 2010)
% relative
improvement
Baseline
(June 2008)
% relative
Most recent
improvement
value (September 2010)
Measure
Percentage of diabetes
patients with:
Process
A1C test in past six months
>90%
37%
78%
111%
89%
90%
1.1%
Retinopathy screening in past
24 months
>90%
27%
28%
6.4%
63%
60%
-5.7%
Comprehensive foot exam in
past 12 months
>90%
11%
40%
281%
85%
73%
-13%
Microalbuminuria screening in
past 12 months
>65%
8.1%
84%
935%
85%
71%
-16%
A1C ≤ 7
>60%
39%
51%
30%
56%
63%
12%
LDL ≤ 2.0 nmol/l
>65%
0.0%
39%
∞
39%
60%
52%
Outcome
Target
Timmins FHT
BP ≤ 130/80
>55%
71%
65%
-8.1%
56%
83%
47%
On ACEI or ARB
>60%
53%
69%
29%
79%
78%
-0.6%
Patients have at least one selfmanagement goal in 12 months
>70%
16%
34%
111%
69%
85%
23%
143
12. Examples of Success
12.6
Examples of success — Congestive heart
failure readmissions
Organization: Ottawa Heart Institute
Results:
Aim and measure: Reduce 30-day readmissions for congestive heart failure
Ottawa Heart Institute has seen a 24% reduction in CHF readmission rates
from 2008/09 to 2009/10.
Ottawa Heart Institute aimed to improve transitions from acute to primary
care and follow-up in the community, by doing the following:
t 1
SPWJEFQBUJFOUTXJUIXSJUUFOEJTDIBSHFDIFDLMJTUTBOEFOTVSJOHQBUJFOUT
understand instructions for their care.
t 6
TFFMFDUSPOJDIFBMUISFDPSET&)3T
UPUSBOTGFSNFEJDBMJOGPSNBUJPOUP
the primary care provider and/or the patient.
t 1SPNPUFBOEUFBDIQBUJFOUTFMGNBOBHFNFOU
t &
NQMPZUFMFIPNFDBSFUFDIOPMPHZUPNPOJUPSDBSEJBDQBUJFOUTBUIPNF
Patients who meet pre-set criteria (e.g., having complex heart failure,
acute arrhythmia or complex cardiac surgery) receive home monitors
which can transmit information such as vital signs over the phone.
t &
NQMPZJOUFSBDUJWFWPJDFSFTQPOTFUFDIOPMPHZUPNPOJUPSTZNQUPNT
adherence to treatment and lifestyle issues like smoking cessation.
Patients receive automated phone calls at regular intervals with a
pre-set series of questions. If the response indicates a worrisome
problem, the call is flagged and the patient receives a call back from a
member of the care team. If the response indicates a high-risk symptom
(e.g. chest pain or shortness of breath), the system holds the patient on
the line and connects him or her directly to medical staff.
144
Ottawa Heart Institute — Congestive Heart Failure Readmission
Rates 2008/09 - 2009/10
14
30 day readmission rate,
congestive heart failure
Change ideas:
12
8.9
7
0
2008/09
2009/10
12. Examples of Success
12.7
Examples of success — Ventilator-associated pneumonia,
central line infection and c. difficile infection
Aims and measures:
Reduce:
– Ventilator-associated pneumonia (VAP) rate per 1,000 bed days
on a ventilator;
– Central line infection (CLI) rate per 1,000 bed days on a central line; and,
– Rate of hospital-acquired C. difficile infection per 1,000 bed days.
Change Ideas:
t %
FWFMPQBTUSPOHDVMUVSFPGQBUJFOUTBGFUZ*OUIFIPTQJUBM
launched the “Single Safety System” initiative with a vision, “an inclusive
and pervasive culture of safety supported by leadership and owned by
all.” Activities to nurture this culture include:
o
o
o
Creating an infection prevention and control (IP&C) service, with a
coordinator who reports to senior management, and “Super Users”
and “Unit Representatives” who provide front-line integration and
organizational support to ensure concerns can be raised in a timely
manner. These peer leaders are trained through IP&C and provide
‘role modeling’ and just-in-time information and training at the
departmental level.
Patient safety walkabouts, where senior leaders interact regularly
with front-line staff on safety issues.
‘Safety Boards’ in each department and monthly open forums called
‘Safety Salutes’, where information on infection rates and prevention
tips are communicated to frontline staff and progress on reducing
infections is celebrated.
t &
NCFEJOUPUIFIPTQJUBMTFMFDUSPOJDNFEJDBMSFDPSEB7"1TDSFFOJOH
tool to ensure consistent daily screening for VAP cases and a ‘ventilator
round sheet’ to ensure consistent patient assessment and documentation. These tools help ensure all standard care practices are
implemented (i.e. use of subglottic drainage endotracheal tubes,
elevation of head of bed, monitoring of cuff pressures, daily sedation
vacations and spontaneous breathing trials to ensure patients are
extubated in the most timely manner possible).
t %
FWFMPQTUBOEBSEQSPUPDPMTGPSFMJNJOBUJOH$-*BOECVJMEBEBJMZ
assessment screening tool into the electronic documentation system.
t *NQMFNFOUB)BOE)ZHJFOF$BNQBJHOJODMVEJOHUIFJOTUBMMBUJPOPG
additional hand rub stations using staff input for optimal placement to
facilitate use according to workflow.
t &
OTVSFFBSMZEFUFDUJPOPG$%JGmDJMFDBTFTCZFNQIBTJ[JOHUISPVHI
IP&C the importance of early specimen collection and reducing lab
turnaround time through a change in the hospital’s external lab partner.
t *NQSPWFQSPDFEVSFTGPSJTPMBUJPO"MMQBUJFOUTXJUITZNQUPNTPGEJBSSIFB
are isolated immediately. Isolation room signage was simplified to
improve understanding and compliance. A patient/care provider video
was implemented for education regarding precautions.
t *NQSPWFDMFBOJOHQSPDFEVSFT"MMJTPMBUJPOSPPNTBSFDMFBOFEUXJDFB
day with Virox. Spray wands were removed from washrooms (as they
can inadvertently splash contaminants throughout a room) and
disposable toilet brushes were added. For patients using bedpans and
commodes, gel liners are used for all cases with diarrhea.
Results:
Collingwood’s C. Difficile infection rate has declined steadily over the past
two years. The hospital has also had zero cases of CLI since January 2009
and zero cases of VAP since October 2009.
Collingwood — C. Difficile Infections
12-month rolling average, C Difficile
infection rate per 1000 bed days
Organizations: Collingwood General and Marine Hospital, a large
community hospital.
1.0
0.5
Collingwood
Provincial Average
0.0
9
l0
Ju
b
Fe
11
145
12. Examples of Success
12.8
Examples of success — Alternative level of care
Organizations:
St. Thomas-Elgin General Hospital
– London Health Sciences Centre — University Hospital site, a major
teaching hospital.
t 1
BSUOFSJOHXJUIPSHBOJ[BUJPOTTVDIBT$$"$TPORVBMJUZJNQSPWFNFOU
activities aimed at improving transitions from acute care to subsequent
care destinations, including the “Home at Last” and “Wait at Home”
programs, and the FLO Collaborative, which reduced and sustained a
one-day reduction in length of stay in the acute medical unit
– Halton Healthcare Services — a very-high-volume community 3 site hospital.
– St. Thomas-Elgin General Hospital — a high-volume community hospital.
Aims and measures:
To reduce the percentage of acute care bed days that are designated as
alternative level of care (ALC).
Change Ideas:
t *NQMFNFOUJOHUIF.FEXPSYYVUJMJ[BUJPONBOBHFNFOUTZTUFNXIJDI
monitors each patient daily to evaluate the level of care requirements
(acute care, rehabilitation, complex care, or home independently or with
community supports)
London Health Sciences Centre — University Site
t 6
TJOHBCFEPQUJNJ[BUJPOTZTUFNPSFMFDUSPOJDCFECPBSEUPPCUBJO
real-time data on bed availability throughout the organization
t 8
PSLJOHXJUI4U+PTFQIT)FBMUI$BSFBOE48$$"$UPDSFBUFBUSBOTJUJPOBM
care unit at Parkwood Hospital to provide short-term restoration care in an
in-patient environment that enables individuals to return to the community.
t 1BSUJDJQBUJOHJOUIFth wave of the Ministry of Health, Emergency
Department Process Improvement Program (ED-PIP) to improve patient
flow through the ED and reduce the wait time for admission to acute care
t 8PSLJOHXJUI$$$"$TBOEIPNFDBSFPSHBOJ[BUJPOTPOJOJUJBUJWFTTVDIBT
o “Safe at Home”, which adds additional service levels, allowing individuals
to avoid hospital or be discharged earlier
t 1
BSUJDJQBUJOHJOUIF3BQJE&NFSHFODZ"TTFTTNFOUGPS$PNNVOJUZ5SBOTJUJPO
project to divert patients who are medically stable from hospital’s emergency
department, preventing hospital admissions and facilitating the patient’s safe
return to home or redirection to alternative settings
o “Wait at Home”, which provides personal care services to enable ALC
patients who are waiting for LTC to wait at home
Results:
t "
EPQUJOHUIF)PNF'JSTUTUSBUFHZJODMVEJOHFOIBODJOHDPNNVOJUZ
resources, changing workflow processes, encouraging greater collaboration among healthcare team members, the hospital and community CCAC
teams, and actively promoting a shift in culture regarding the care and flow
of elderly patients.
t *OUSPEVDJOHB+PJOU%JTDIBSHF0QFSBUJPOT(SPVQDPNQSJTJOHUIFNBOBHFS
of social work and discharge planning, the hospital’s chief operating officer
and the community care access centre (CCAC); the group reviews every
ALC patient and potential ALC patients, initiates early referrals to the
CCAC, discusses options for discharge and ensures that each patient
has a clear discharge plan.
146
All three hospitals have shown reduction in the percentage of acute care bed
days that are designated as ALC. In particularly, Halton Healthcare Services
Corporation — Oakville site and St. Thomas-Elgin General hospital had a
relative improvement of over 50%.
Percentage of acute care bed days that are designated as ALC
20
Percent
Halton Healthcare Services
St. Thomas-Elgin General Hospital
10
Halton Healthcare Services
Corporation — Oakville
London Health Sciences
Centre — University Hospital Site
0
2008/09
2009/10
13. Endnotes
13
1
2
3
4
5
6
7
8
9
10
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12
13
14
15
16
17
18
19
20
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22
23
24
25
26
27
28
29
30
31
32
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14. Acknowledgements
14
Acknowledgements
Development of this report was led by a scientific team from Health Quality Ontario (HQO) including Ben Chan, Rebecca Comrie, Michelle Rey, Imtiaz Daniel
and Geoff Anderson, and a project management/epidemiology/communications team from HQO that included Maggie Chen, Katherine McLaughlin, Ryan
Emond, Ja Young Kim, Sisi Wang, Brad Kim, Laura Corbett, Wilson Kwong, Susan Brien, Céline St-Louis, Colin Longhurst, Ivan Langrish, Suzanne Dugard and
Nilam Kassam. Analyses were also provided by Astrid Guttmann, Chad Leaver and Jun Guan from the Institute for Clinical Evaluative Sciences (ICES).
Health Quality Ontario acknowledges and thanks the many dedicated individuals who contributed to this report, including:
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t )20T1FSGPSNBODF.FBTVSFNFOU"EWJTPSZ#PBSEBHSPVQPGSFTFBSDIBOENFBTVSFNFOUFYQFSUTGSPNBSPVOEUIFQSPWJODFXIPQSPWJEFEBEWJDF
on the selection of indicators: Imtiaz Daniel (chair), Arlene Bierman, Geoff Anderson, Sten Ardal, Suzanne Dionne, Faith Donald, Alan Forster, Bob
Gardner, Gillian Hawker, Cam Mustard, Raymond Pong, Walter Rosser, Carol Sawka, Katya Duvalko, Kaveh Shojania, Sam Shortt, Eugene Wen and
Michael Wolfson.
t )20T1FSGPSNBODF.FBTVSFNFOU1FFS3FWJFX1BOFMBHSPVQPGSFTFBSDIBOENFBTVSFNFOUFYQFSUTGSPNBSPVOEUIFQSPWJODFXIPQSPWJEFEBEWJDFPO
all quantitative research and analysis: Geoff Anderson, Helen Angus, Sten Ardel, Chaim Bell, Jennifer Bennie, Arlene Bierman, Patti Cochrane, Suzanne
Dionne, Faith Donald, Katya Duvalko, Kevin Empey, Alan Forster, Michael Gardam, Bob Gardner, Amir Ginzburg, Andrea Gruneir, Astrid Guttman, Christey
Hackney, Simon Hagens, Gillian Hawker, Sherrie Hertz, Luidmila Husak, Jon Irish, Anthony Jonker, Maureen Kelly, Kori Kingsbury, Paul Kurdyak, Hussein
Lalani, Elizabeth Lin, Ian McKillop, Charlotte Moore, Cam Mustard, Adam Nagler, Howard Ovens, Raymond Pong, Jeff Poss, Dan Purdham, Paula
Rochon, Walter Rosser, Carol Sawka, Lloy Schindeler, Michael Schull, Baiju Shah, Kaveh Shojania, Sam Shortt, Kevin Smith, Ann Sprague, Terry Sullivan,
Beth Thesis, Jack Tu, Tamara Wallington, Eugene Wen, Walter Wodchis and Vandad Yousefi.
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Ontario, College of Nurses of Ontario, College of Physicians and Surgeons of Ontario, Commonwealth Fund, HIMSS Analytics, NRC-Picker, Ontario
Hospital Association, OntarioMD, Ontario Physician Human Resources Data Centre, Ontario Public Health Laboratories, Organisation for Economic
Co-operation and Development, Statistics Canada and the Workplace Safety and Insurance Board.
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Hospital (Halton Healthcare Services), Halton Healthcare Services Corporation — Oakville, London Health Sciences Centre — University Hospital Site,
Mount Sinai Hospital, North York FHT, North York General Hospital, Oakville-Trafalgar Memorial Hospital (Halton Healthcare Services), Ottawa Heart
Institute, Petawawa Centennial FHT, Smithville Medical Centre FHT, St. Joseph’s Health Care — London, St. Thomas — Elgin General Hospital, Timmins
FHT and Windsor Regional Hospital.
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159
15. Members of Health
Quality Ontario
the OHQC
15
Access
Members
to of
Primary
HealthCare
Quality Ontario
All Ontarians should have a regular family doctor - preferably, one who works in a team with nurses and other health care providers. The
primary care team knows the person’s medical history, diagnoses and treats new problems, monitors chronic conditions, offers preventive
health services and coordinates referrals to specialists when needed. It’s important to make sure that when people need a particular
service from their family doctor, they shouldn’t have to wait too long.
Board
Lyn McLeod (Newmarket)
Chair, Health Quality Ontario
Interim Chair, Governance and Nominations
Chair, Management and Resources Committee
Gilbert Sharpe (Toronto)
Member, Management and Resources Committee
Richard Alvarez (Toronto)
Andy Molino (Ottawa)
Chair, Audit & Resources Committee
Member, Management and Resources Committee
Dr. Arlene Bierman (Toronto)
Member, Performance Measurement Advisory Board
Dr. André Hurtubise (New Liskeard)
Member, Governance and Nominations
Faith Donald (Toronto)
Member, Performance Measurement Advisory Board
Member, Audit & Resources Committee
Bob Gardner (Toronto)
Member, Performance Measurement Advisory Board
Biographies are posted at www.hqontario.ca/en/governance.php.
Management
Dr. Ben Chan
President & Chief Executive Officer
Nizar Ladak
Vice President & Chief Operating Officer
Eileen Patterson
Vice President, Quality Improvement
Harpreet Bassi
Director, Strategic Projects
Céline St-Louis
Director, Communications
Mandate
The functions of Health Quality Ontario are:
(a) to monitor and report to the people of Ontario on,
(i) access to publicly funded health services,
(ii) health human resources in publicly funded health services,
(iii) consumer and population health status, and
(iv) health system outcomes;
(b) to support continuous quality improvement;
(c) to promote healthcare that is supported by the best available scientific evidence by,
(i) making recommendations to healthcare organizations and other entities on standards of care in the health system, based on or
respecting clinical practice guidelines and protocols, and
(ii) making recommendations, based on evidence and with consideration of the recommendations in subclause (i), to the Minister
concerning the Government of Ontario’s provision of funding for healthcare services and medical devices.
160
HEALTH QUALITY ONTARIO
130 Bloor Street West, Suite 702
Toronto, ON M5S 1N5
Telephone: 416.323.6868
Toll-free: 1.866.623.6868
Fax: 416.323.9261
Email: [email protected]
www.hqontario.ca
ISSN 1926-2191 (Print)
ISBN 978-1-4435-5554-8 (Print, 2011 ed.)
ISSN 1925-7015 (Online)
ISBN 978-1-4435-5555-5 (HTML, 2011 ed.)
ISSN 1925-7015 (Online)
ISBN 978-1-4435-5556-2 (PDF, 2011 ed.)
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